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Columbia  ^nibcrfiitp 
in  tf}t  Citp  of  i^eto  l^orfe 

CoUegc  of  ^!)j»gicians;  anb  burgeons! 


l^titxtntt  Hibrarp 


FRACTURES  AND  DISLOCATIONS 


Digitized  by  the  Internet  Archive 

in  2010  with  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/fracturesdislocaOOpres 


FRACTUKES 

AND 

DISLOCATIONS 

DIAGNOSIS  AND   TREATMENT 


BY 

MILLER  E.  PRESTON,  A.B.,  M.D. 

FIRST    LIEUT.    M.    R.    C,    U.    S.    A.  ;    SURGICAL    EXAMINER,    COLORADO    STATE     BOARD    OF     MEDICAL 
EXAMINERS  ;    FORMERLY    POLICE    SURGEON,    CITY    AND    COUNTY    OF    DENVER,    INSTRUCTOR 
IN    ANATOMY,     UNIVERSITY    OF    DENVER,     AND    VISITING     GYNECOLOGIST     TO 
CITY    AND    COUNTY     HOSPITAL,     DENVER,     COLORADO. 


WITH  A  CHAPTER  ON 

RONTGENOLOGY- 

BtH.  G.  stover,  M.D. 

PROFESSOR    OF    RONTGENOLOGY,    SCHOOL    OF    MEDICINE,     UNIVERSITY    OF    COLORADO;     MEMBER     OP 

AMERICAN     RONTGEN     RAY     SOCIETY  ;     VISITING     RONTGENOLOGIST     TO     CITY     AND     COUNTY 

HOSPITAL,   ST.  JOSEPH'S   HOSPITAL  AND   CHILDREN'S    HOSPITAL,    DENVER,    COLORADO. 


860  ILLUSTRATIONS 


ST.  LOUIS 
C.  V.  MOSBY  COMPANY 

1915 


CoPVKIi;llT.    1915,    BY    C-    v.    MoSBV    CoMPANV 


M  y 


PrexK  (if 

C.  Y.  Moshil  Ciiinpanii 

St.  Louis 


TO 

CHAS.  B.  LYMAN,  M.D.,  F.A.C.S. 

From  Whom  the  Author  Received 

His  First  Instruction 

IN  Fractures  and  Dislocations 


FOREWORD 

The  object  of  this  book  has  been  to  offer  the  reader  a  working 
knowledge  of  the  subject  in  as  few  words  as  possible,  avoiding  for 
the  most  part  all  theories  and  arguments  which  are  void  of  practical 
value  for  the  surgeon  who  has  to  diagnose  and  treat  the  various  in- 
juries which  are  met  with  in  actual  practice.  The  author  has  en- 
deavored to  make  the  reader  an  eye  witness  to  the  various  deformi- 
ties as  they  appear  immediately  following  the  accident,  rather  than 
to  offer  him  lengthy  text  in  describing  the  lesions.  There  is  much  to 
be  learned  by  inspection  in  the  average  case  of  fracture  or  dislo- 
cation, and  the  information  thus  gained  may  be  put  to  immediate 
use  with  a  minimum  amount  of  manipulation  of  the  parts  and 
without  being  obliged  to  await  the  returns  of  an  X-ray  examination. 
The  more  one  learns  by  inspection,  in  establishing  a  diagnosis  in 
a  given  case,  the  less  there  remains  to  be  determined  by  palpation, 
and  if  the  surgeon  develops  the  faculty  of  recognizing  what  he  sees 
the  patient  will  many  times  be  relieved  of  much  unnecessary  manip- 
ulation and  suffering  to  say  nothing  of  the  damage  which  may  be 
inflicted  on  the  already  traumatized  soft  tissues.  Photography, 
therefore,  is  the  best  means  of  recording  the  initial  deformities, 
but  the  excitement,  confusion  and  pain  attending  the  average  case 
of  fracture  are  conditions  anything  but  favorable  for  picture- 
taking.  Moreover  the  varying  conditions  of  light  and  the  sur- 
roundings in  which  we  find  the  patient,  together  with  the  neces- 
sity of  having  the  photographic  apparatus  available  and  in  good 
working  order,  are  additional  factors  which  work  against  the  se- 
curing of  such  valuable  clinical  data  and  explain  the  scarcity  of 
pictures  of  these  deformities  in  medical  literature.  The  illustra- 
tions of  such  deformities  shown  on  the  following  pages  have  been 
taken  under  unfavorable  circumstances,  in  a  large  proportion  of 
cases,  and  (although  the  photographic  appliances  were  the  best 
obtainable  including  the  fastest  Goerz  and  Zeiss  anastigmat  lenses) 
the  results,  from  a  photographic  standpoint,  have  been  none  too 
good  in  many  instances.  The  pictures  shown  have  been  chosen 
from  a  large  number  of  such  photographs  with  the  intention  of 


\n\  FOREWORD 

familiarizing  the  reader  with  the  average  clinical  defonnity,  rather 
than  for  the  pur[)ose  of  recording  rare  cases  or  those  in  which  tiie 
pathology  is  obscure. 

The  time-honored,  academic  classification  of  fracfnres  under  one 
heading  and  dislocations  under  another  has  been  abandoned,  and 
the  more  practical  method  of  eonsidei-ing  the  injuries  according 
to  the  region  in  which  they  occur  has  been  followed.  Thus  the 
reader  will  find  all  the  injuries  to  which  a  given  region  is  sub- 
ject (including  fractures,  dislocations,  joint  fractures  and  frac- 
ture-dislocations) without  looking  up  the  different  conditions  in 
widely  separated  sections  of  the  book  or  even  consulting  another 
volume. 

The  development  of  the  Rontgen  ray  has  been  of  inestimable 
value  in  the  diagnosis  of  fractures  and  dislocations,  and  its  use 
cannot  ])c  too  highly  commended;  but,  on  the  other  hand,  this 
very  aid  has  resulted  in  our  becoming  more  lax  in  other  methods 
of.  diagnosis.  The  X-ray  is  a  most  valuable  supplement  to  other 
physical  clinical  methods  but  it  should  not  be  expected  to  sup- 
plant them.  The  surgeon  should  make  a  practice  of  determining 
the  nature  and  location  of  the  fracture  as  accurately  as  possible 
(due  care  being  exercised  to  avoid  unnecessary  manipulation)  be- 
fore the  X-ray  is  taken,  and  later  to  compare  his  conception  of  the 
condition  with  the  Rontgenogram.  By  making  this  a  routine  meas- 
ure he  will  find  that  his  diagnostic  acumen  will  be  materially  in- 
creased as  time  goes  on. 

A  certain  mechanical  sense  is  most  essential  in  the  treatment  of 
fractures  and  dislocations,  and  no  text-book  can  supply  this  to  one 
naturally  deficient  in  this  respect.  However,  an  attempt  has  been 
made  in  the  following  pages  to  supply  the  necessary  data  for  the 
development  of  this  sense  and  to  place  before  the  reader,  as  far 
as  possible,  some  of  the  author's  experiences. 

The  more  common  fractures  have  been  accorded  the  greatest 
amount  of  attention  since  they  are  the  conditions  with  which  the 
average  practitioner  will  have  to  deal  most  frequently. 

Occasion  is  here  taken  to  thank  a  number  of  members  of  the 
medical  profession  in  Denver  who  have  been  of  service  in  various 
ways  in  obtaining  the  material  for  and  in  the  preparation  of  this 
work.  Among  others  the  author  wishes  particularly  to  express  his 
gratitude  to:  Drs.  C.  B.  Lyman,  T.  E.  Carmody,  Leonard  Ely, 
H.  R.  ]\IcGraw,  Benj.  Matthews,  V.  D.  .McKelvey,  J.  M.  Barney, 


PXJREWORD  IX 

R.  K.  Beere,  W.  G.  Mudd,  C.  B.  Ackley,  II.  G.  Harvey,  Traeey  Love, 
E.  W.  Lazell,  W.  M.  Wilkinson,  S.  B.  Childs,  L.  G.  Crosby,  J.  B. 
Davis,  Mr.  Frank  Barmettler  and  members  of  the  staff  and  in- 
ternes of  the  City  and  County  Hospital. 

Due  credit  for  the  few  illustrations  not  original  is  given  in  the 
legends  accompanying  them. 

The  chapter  on  the  use  of  the  Rontgen  ray  is  written  by  Dr.  H. 
G.  Stover,  and  most  of  the  Rontgenograms  have  been  taken  for  me 
by  him,  or  have  been  drawn  from  his  collection  of  over  thirteen 
thousand  plates. 

Miller  E.  Preston. 
Uknvee,  Colorado. 


CONTENTS 


Chapter 


II. 

III. 

IV. 

V. 

VI. 

VII. 

VIII. 

IX. 

X. 

XI. 

XII. 

XIII. 

XIV. 

XV. 

XVI. 

XVII. 

XVIII. 

XIX. 

XX. 


XXI. 

XXII. 

XXIII. 

XXIV. 


PART  I. 

UPPER  EXTREMITY. 

Page 
Fractures  of  the  Clavicle  and  Injuries  to  the  Clavicu- 
lar Articulations 3 

Dislocations  of  the  Sternal  End  of  the  Clavicle     .      .       5 

Fractures  of  the  Clavicle 11 

Dislocations  of  the  Outer  End  of  the  Clavicle     ...     30 

Fractures  of  the  Scapula 37 

Dislocations  of  the  Shoulder 44 

Fractures  of  the  Upper  End  of  the  Humerus  ....     82 

Fractures  of  the  Shaft  of  the  Humerus 108 

Fractures  of  the  Lower  End  of  the  Humerus       .      .      .   120 

Dislocations  of  the  Elbovp        154 

Dislocations  of  the  Ulna  Alone  (Rotary)  ....  175 
Dislocations  of  the  Head  of  the  Radius     .....   177 

Fractures  of  the  Bones  of  the  Forearm 184 

Fractures  of  the  Upper  End  of  the  Ulna 185 

Fractures  of  the  Upper  End  of  the  Radius  ....  197 
Fractures  of  the  Radial  and  Ulnar  Shafts  ....  204 
Fractures  of  the  Lovfer  End  of  the  Ulna     .         ...   232 

LXTXATIONS   OF   THE  LOVFER  EnD  OF  THE  UlNA 237 

Fractures  of  the  Lower  End  of  the  Radius     ....   242 
Injuries  to  Carpus   (Dislocations  of  Wrist,  Medico-car- 
pal Luxations  and  Fractures  and  Dislocations  of  the 

Individual  Carpal  Bones) 277 

Luxations  of  the  Carpometacarpal  Articulation  .  .294 
Fractures  of  the  Metacarpals 297 

OAT 

Fractures  of  the  Fingers 

Dislocations  of  the  Fingers  .      ; 


XXV. 

XXVI. 

XXVII. 

XXVIII. 

XXIX. 


PART  II. 

HEAD  AND  TRUNK. 

Fractures  of  the  Nose 

Fractures  of  the  Malar  Bone  and  Zygomatic  Arch  .      .  334 

Fractures  of  the  Superior  Maxilla ^43 

Fractures  of  the  Lower  Jaw 

37f5 
Dislocations  of  the  Jaw 

xi 


Xll  CONTENTS 

Chapter  Page 

\\\.     ScAi.p   Wounds 370 

\.\.\l.        I-'KACTIKKS    OF    THE    SkUI.L       .        .              liit  1 

.\.\\ll.     Fkactiues  of  the  Stekmm      ...          4.'):{ 

X.WIII.        Fk.VCTIKES    of    the    IvIHS 4.")!t 

.\\\l\.     Kkactuke-Dislocations  of  the  Spine 4(>.") 

WW.     Fractures   and    Dislocations   of   the    Pelvis     ....  4!t'2 

PART  III. 

LOWER  KXTRKMITV. 


WW  1. 
XXXVll. 

WW!  II. 

X.WIX. 

XL. 

XLl. 

XLI  I. 

\L11J. 

XLI\  . 

XL\  . 

XL\  J. 

XLVIl. 

XLVIJI. 

XLIX. 

L. 

LI. 

LIL 

Llll. 

LI\  . 

L\  . 

L\  J. 


Dislocations  of  the  Hip .')L") 

Fractures  of  the  Upper  End  of  the  Femir       ....   531 

Fractures  of  the  Femoral  Shaft         .>58 

Fractures  of  the  Lower  End  of  the  Fe.muk  ....  374 
Fkactukes  and  Luxations  of  the  Semiunah  Cartilages  .   587 

Fractures  of  the  Patella 594 

Dislocations  of  the  Patella (Ktit 

Dislocations  of  the  Knee 1^3 

INJURIES  Just  Below  the  Knee — Fractures  of  the  J'iiua 

and    Fibula    (Upper    Ends) ()20 

Fractures  of  the  Shafts  of  the  Bones  of  the  Leg  .   t)34 

Pott's   Fracture (io!) 

Fractures  of  the  Lower  Ends  of  the  Tibia  and  Fibula    .    (575 

Dislocations  of  the  Ankle t)84 

Fr.\ctx'res  and  Dislocations  of  the  Astragalus     .  .   (592 

Subastragalar   Luxations 699 

Fractures  and  Dislocations  of  the  Calcaneus     .      .      .   703 

Medio-Tarsal   Luxations 709 

Fractures   and  Luxations   of  the  Cuboid,  Scaphoid  and 

Cuneiforms 710 

Tarso-!Metatarsal   Luxations 713 

Fractures  of  the  Metatarsals 714 

Fractures  and  Lixations  of  the  Phalanges     ....    7?.(> 


PART  IV. 
SPECIAL  SUBJECTS. 


L\  11.  Terms  and  Definitions 725 

L\lil.  The  Use  of  the  X-Ray.  By   II.  (!.  Stover,  M.D.     .      .      .   735 

J^IX.  The  Open  Treatment  of  Fractures 754 

LX.  Bone  Transplantation 771 

LXl.  Treatment  of  Compound  Fractures    .\nd    Dislocations    .    789 


ILLUSTRATIONS. 


FIG.  PAGE 

1.  Mviscular  and  ligamentous  attachments  of  clavicle 5 

2.  iSuperior   surface   of   right   clavicle 12 

3.  Inferior    surface    of    right    clavicle 12 

4  and  5.     Internal    structure    of    right    clavicle 12 

6.  Relation  of  brachial  plexus  to  first  rib  and  clavicle 13 

7.  Fracture  of  clavicle  in  child.     Rontgenogram 13 

8.  Fracture  of  clavicle  in  its  inner  third.     Rontgenogram    ....  14 

9.  Greenstick  fracture  of  clavicle.     Rontgenogram 14 

10.  Fracture  of  middle  of  clavicle.     Rontgenogram 15 

11.  Fracture  of  clavicle  with  usual   deformity.     Rontgenogram        .      .  15 

12.  Comminuted  fracture  of  outer    end    of    clavicle.     Rontgenogram      .  16 

13.  Comminuted  fracture  of  clavicle.     Rontgenogram         16 

14.  Fracture    of   right    clavicle    (recent).     Photograph 17 

15.  Recent  fracture  of   clavicle.     Photograph 17 

16.  Side   view   of    same   case 17 

17.  Recent   fracture  of  right  clavicle.     Photograph 18 

18.  Side   view   of   same   case 18 

19.  Fracture  of  clavicle  24  hours  old.     Photograph 18 

20.  Side   view   of   same   case 18 

21.  Recent    fracture    of    left    clavicle.     Photograph 19 

22.  Another   view   of   same   case 19 

23.  Delayed   union   of   fractured   clavicle.     Photograph 19 

24.  Another  view   of   same  case 19 

25.  Fracture   of   clavicle   in    elderly   woman.     Photograph      ....  20 

26.  Old  fracture  of  clavicle  with  deformity.     Photograph      ....  20 
27  and  28.     Demonstrate  the  outlines  of  clavicles.     Photographs      .      .  21 

29.     Recent    fracture    of    right   clavicle 23 

30  to  33.     Application  of  modified   Sayre's  dressing 24 

34.  Molar's   figure-of-eight .  25 

35.  The  application  of  Velpeau's  bandage 25 

36.  Case  showing  result  of  recvimbent  treatment 26 

37  and  38.     C.  F.  Taylor's  brace 27 

39.  Dislocation    of   outer    end   of   clavicle   and   separation   of   acromial 

epiphysis.     Rontgenogram 31 

40.  Recent  dislocation  of  outer  end  of  clavicle.     Photograph      ...  32 

41.  Dislocation   of   outer   end  of   clavicle.     Photograph 33 

42.  Lateral   view   of    same   case 33 

43.  Downward  dislocation  of  outer  end  of  clavicle.     Photograph      .      .  34 

44.  Dressing  for  dislocation  of  outer  end  of  clavicle 35 

45.  Same   principle  carried   out   with  adhesive   plaster 35 

46.  Ventral    surface    of   right    scapula 37 

47.  Dorsal  surface  of  right  scapula 37 

48.  View  of  right  scapula  from  axillary  border .38 

49.  Fracture  of  neck  of  scapula.     Rontgenogram 39 

50.  Palpation   of   scapula 41 

51.  Strapping   of   chest  for   fracture   of   scapula 42 

52.  Action  of  capsule  in  adduction  of  arm.     Diagram 43 

53.  Action  of  capsule  in  abduction  of  arm.     Diagram 43 

54.  Bones    of    normal    shoulder 47 

55.  Subcoracoid    dislocation 47 

56.  Intracoracoid  or  subclavicular  dislocation .      .47 

xiii 


XIV  ILLUSTRATIONS 

FIG.  PAGE 

57.  Intraclavicular  dislocation  with  moderate  deformity 47 

58.  Subglenoid   dislocation 48 

59.  Luxatio    ereeta 48 

CO.     Subacromial    dislocation    of    shoulder 48 

61.  Subspinous  dislocation  of  shoulder 48 

62.  Low   subcoraeoid   dislocation.     Kontgenograni 50 

63.  Recent  subcoraeoid  dislocation   of   left  shoulder 52 

64.  Subcoraeoid   dislocation    of    left    slioulder 53 

05.  Examination  of  same  ease  showing  depression  below  acromion    .      .  53 

66.  Recent    subcoraeoid    dislocation    of    right    shoulder 54 

67.  Another   view   of   same   case 54 

68.  Another   view   of   same   case 55 

69.  Recent    subcoraeoid    dislocation    of    right    shoulder 55 

70.  Another  view   of   same  case 55 

71.  Low  subcoraeoid   dislocation   of   shoulder 50 

72.  Low  subcoraeoid  dislocation   of   shoulder 56 

73.  Another   view   of   same  case 56 

74.  Palpating  recent  subglenoid  dislocation  of  shoulder 57 

75.  Palpating  recent  subglenoid  dislocation  of  shoulder 57 

76.  Retentive   dressing    for    dislocation    of    shoulder 58 

77.  Recent  typical  subglenoid  dislocation  of  left  shoulder      ....  59 

78.  Recent  subcoraeoid  dislocation  of  left  shoulder 59 

79.  Attitude  of  lea.st  pain   in   subcoraeoid  dislocation 59 

80.  Attitude  of  least  discomfort  in  subglenoid  dislocation      ....  60 

81.  Another   view   of  same  case 60 

82.  Luxatio    ereeta 61 

83.  Another  view   of  same  case 61 

84.  Posterior    dislocation    of    right    shoulder 62 

85.  Another  view  of  same  case.     Palpation    of    liead 62 

86.  Another  view  of  same  case 63 

87.  Case   of   avulsion   of   upper   extremity      .     • 63 

88.  Subcoraeoid  dislocation  in   fleshy   woman 64 

89.  Subcoraeoid  dislocation  of  shoulder   in  fleshy   man 65 

90.  Subcoraeoid  dislocation  of    right    shoulder         67 

91.  First  step  in   Kocher's  method 67 

92.  Second    step    in    Kocher's    method 67 

93.  Third  step  m  Kocher's  method 67 

94.  Illustrating   principles    of    Kocher's   method 68 

95.  McBurney's   hook 72 

90.  Dislocation  of  shoulder  complicated  by  fracture  of  anatomical  neck 

of    humerus 72 

97.  Rontgenogram  of  same  case  before  operation 73 

98.  Rontgenogram  of  same  case  after  operation 73 

99.  Same  case  after  operation 74 

HJO  and  101.     Stereoscopic  Rontgenogram  of  fracture  and  dislocation  of 

shoulder 74 

102.  Subcoraeoid  dislocation  with  fracture  of  greater   tuberosity      .      .  75 

103  and   104.     Contracture  following  dislocation  of  shoulder      ....  76 

105,  100  and   107.     Old    unreduced    dislocation    of    shoulder      ....  78 

108.  Recurrent    dislocation    of    shoulder 79 

109.  Upper  end  of  humerus 83 

110.  Structure  of  upper  end  of  humerus .      .  83 

111.  Rontgenogi'am  of  upper  end  of  humerus  showing  epiphyseal  carti- 

lage            84 

112.  Rontgenogram  of  fracture  of  anatomical  neck  of  humerus    ...  85 

113.  Rontgenogram  of  fracture  of  surgical  neck  of  humerus   ....  86 

114.  Rontgenogram  of  comminuted    fracture    of    surgical    neck      ...  87 

115.  Rontgenogram  of  fracture  of  surgical  neck 68 

116.  Rontgenogram  of  fracture  of  surgical  neck 89 

117.  Recent  fracture  of  surgical  neck  of  humerus 90 


ILLUSTRATIONS  XV 

FIG.  PAGE 

118.  Another   view  of  same  case 90 

119.  Same  case  seen  in  recumbent  position 90 

120.  Rontgenogram  of   fracture  of   surgical   neck 91 

121.  Fracture  of  surgical  neck  of  humerus 91 

122.  Another  view  of  same  case 92 

123.  Rontgenogram  of  same  case 93 

124.  Low  fracture   of   surgical  neck 93 

125.  Same  case  seen  in  recumbent  position 94 

12G.     Old  fracture  of  surgical  neck 94 

127.  Lateral   view   of    same   case 94 

128.  Rontgenogram  of  same  case 95 

129.  Measuring    length    of    humerus 96 

130.  Palpating  humeral  head  during  rotation 96 

131.  Palpating  liumeral  head  through  axilla 96 

132.  Cigar-box  boards  used  in  making  axillary  pad 98 

133.  Axillary  pad  completed 99 

134.  135  and  136.     lliree  views  of  axillary  pad  in  place 99 

137.  Plaster    shoulder    cap 101 

138.  Axillary  pad  in  position  and  arm  bandaged 101 

139.  Same  after  the  plaster  shoulder  cap  has  been  applied     ....    101 

140.  Body  swathe  used  to  secure  arm  to  side  and  act  as  sling     .      .      .    101 

141.  Middledorf    triangle 102 

142.  Monks  triangle 102 

143.  Osgood-Penhallow   splint 102 

144.  Plaster  cast  applied  with  arm  in  abduction 104 

145.  Plaster  cast  applied  with  arm  in  abduction;    forearm  raised     .      .    104 

146.  Anterior  surface  of  right  hvimerus 109 

147.  Posterior  surface  of  right  liumerus 109 

148.  Spiral,  comminuted  fracture  of  humerus.     Rontgenogram     .      .      .110 

149.  Fracture   of   humeral   shaft.     Rontgenogram 110 

150.  Multiple  fracture  of  humeral  shaft.     Rontgenogram   .      .      .      .      .    Ill 

151.  Oblique  fracture  of  humeral  shaft.     Rontgenogram Ill 

152.  Recent  fracture  of  shaft  of  left  humerus 112 

153.  Crushing  injury  of  arm.     Fracture  of  humeral  shaft     .      .      .      .112 

154.  Stromeyer    cushion 114 

155.  Axillary  pad  in  place  and  arm  bandaged 114 

156.  Coaptation  splints  applied  to  arm 114 

157.  Body  swathe   applied 114 

158.  Rontgenogram  of  spiral  fracture  of  humeral  shaft 117 

159.  Same  after  operation  and  reduction  with  internal  fixation      .      .      .117 

160.  Rontgenogram  of  same  case  nine  months  later 118 

161.  162  and  163.     Photographs  of  bone    (same  case)    showing  result      .    118 

164,  165  and  166.     Views   of    lower    end   of   humerus 120 

167  and  168.     Rontgenogram  of  fracture  of  lower  end  of  liumerus      .      .121 

169  and  170.     Rontgenogram  of  fracture  of  lower  end  of  humerus      .      .    122 

171  to  174.     Rontgenogram  of  fracture  of  lower   end  of  humerus      .      .    123 

175  to  178.     Rontgenogram  of  fracture   of  lower  end  of  humerus      .      .    124 

179.  Fpipliyseal   separation   of   epitrochlea.     Rontgenogram      ....    125 

180.  Lateral  view   of   same   case.     Rontgenogram 125 

181.  Rontgenogram  of  fracture  of  internal   epicondyle 126 

182.  Rontgenogram  of  epipliyseal  separation  of  external    condyle      .      .    126 

183.  Rontgenogram  of  epiphyseal  separation  of  internal    epicondyle       .    126 
1184.  Recent  fracture  of  external    epicondyle   with    deformity        .      .      .    129 

185.  Recent  fracture  of  lower  end  of  liumerus 130 

186.  Another  view  of  same  case 130 

187.  Recent  fracture   of   lower   end   of  humerus.      (Splitting.)      .      .      .    130 

188.  Recent  transverse  fracture   of   lower   end   of  humerus     ....    132 

189.  Another  view  of  same  case  in   sitting  position 132 

190  and  191.     Rontgenograms  of  same  case 133 

192.  Recent  compound  comminuted  fracture  of  lower  end  of  humerus      .    133 


XVl  ILLUSTRATIONS 

FIO.  r.\GE 

193.  Another   viow   of   samo  oaso I'.VA 

194.  Ki'Ci'iit  compouiul  comiiiiimtfd  fracture  oi  lower  i-iul  of  Imiiicius  i:{4 

195.  Another   view    of   same   ease l.M 

196.  Old  <;unstoek  deformity  result  of  fracture  almve  and  lich)\\   ell)o\v     .  135 

197.  Anotlu'r   view   of   same   case 135 

198.  Old  ease  of  diaeondylar  fracture  of  lower  end  of  humerus  .  13() 

199.  Another   view   of   same   case 13(1 

200.  Examination  of  case  in   which   carrying  angh-  luis  heen    lost  .  137 

201.  Examiiuition  of  same  case  with   elhows  extended 137 

202.  I'Xamination   of  jtronouneed   uinistoek   defoi-mity    in   Ih'xion    .  .  138 

203.  Same  ease   with   ell)ow   extended 138 

204.  Another    view    of    same    case 139 

205.  Old  fracture  of  lower  end  of  humerus  with  musculo-si)iral  ]iaralysis  140 

206.  Another  view  of  same  case  showino;  contracture 141 

207.  Same  case  seen   from  ulnar   side  of   forearm 141 

208.  Case  of  cuhitus  varus  in  one  arm  and  cubitus  valgus  in  tlie  other    .  142 

209.  Pronounced  normal  carrying  angle 142 

210.  Dressing    for    treating    arm    with    elhow    in    Hexion 145 

211.  Du])uy    internal    riglit-angle    splint 146 

212.  Dupuv    extenuU    right-angle    splint 146 

213.  Internal  riglit-angle  splint  a])i)lied 146 

214.  Internal  right-angle  splint  with    traction 146 

215.  Plaster    splints    for    ui)i)er    extremity 147 

216  and  217.     Adjustable  s])lints  for  elbow 148 

218.  Splitting  of  lower  end  of  humerus.     Rontgenogram 149 

219.  Rontgenogram  of  same  case  five  years  after  operation      ....  149 
220  and  221.     Range  of  motion   in   elbow  of   same  case  five  years   after 

operation 150 

222  and  223.     Ligaments  of  elbow 154 

224.  Recent   posterior   dislocation    of   right   elbow 157 

225,  226  and  227.     Additional    views   of   same  case      ....    157  and  158 

228.  Recent  posterior  dislocation  of  left  elbow 159 

229.  Palpating  head   of  radixis  and  empty   sigmoid   in   same  case     .      .  159 

230.  Posterior  view  of  same  case 160 

231.  Lateral  dislocation   of  elbow 160 

232.  Another   view   of   same   case 160 

233.  234  and  235.     Diagrammatic  comparison  of  posterior  dislocation  of 

elbow,    supracondylar    and   diaeondylar    fractures 163 

236.  Swelling  of  elbow  following    simple    strain 164 

237.  Swelling  of  elbow  24   hours   following  dislocation 165 

238.  Another   view   of   same   case 165 

239.  Rontgenogram    of    forward    dislocation    of    eliiow    with    fracture    of 

olecranon 166 

240.  Rontgenogram  of   fracture  of   coronoid  complicating  backward  dis- 

location of  elbow 166 

241.  Backward  dislocation  with  fracture  of  tip  of  coronoid.     Rontgeno- 

gram          167 

242.  Backward  dislocation   with   comminuted   fracture  of  coronoid  proc- 

ess.    Riintgenogram 167 

243.  Fracture  of  coronoid  \\ith  displacement  i)roduced  by  backward  dis- 

location  of   elbow.     Rontgenogram 167 

244.  Fracture  of  coronoid  with   slight  displacement.     Rontgenogram      .  167 

245.  Method  of  reducing  backward  dislocation   of  elbow 168 

246.  Another   method   of  reducing  Imckward   dislocation    of   elbow            .  168 
247  and  248.     Range  of  motion  fourteen  days  following  backward  dislo- 
cation   of    ell)ow 172 

249.     Forward  dislocation  of  head  of  radius 179 

250  and  251.     Rontgenograms  of  same  case 179 

252.  Fracture  of  olecranon.     Rrmtgonogram 186 

253.  Fracture    of    olecranon;    elbow    extended.     Rontgenogram  .187 


ILLUSTRATIONS  XVll 

FIG.  I'AGE 

254.  Same   case;    elbow    sliglitly    Hexed.      Roiitj^eiioKi'Hrn 187 

255.  Fracture  of  olecranon  one  week  following  accident 189 

256.  Palpation    of    same    case 189 

257.  The  straight  splint  used  in  the  treatment  of  fractures  of  the  ole- 

cranon      191 

258.  Fracture  of  olecranon.     Uontgenogram 193 

259.  Same  case  after  operation  with  internal  fixation 193 

260.  The  use  of  passive  motion  following  fracture  of  olecranon      .      .      .195 

261.  Fracture  of  head  and  neck  of  radius.     Rikitgenogram      ....    197 

262.  Comminvited   fracture  of   head  of   radius.     Rontgenogram      .      .      .197 

263.  Fracture  of  head  and  neck  of  radius.     Rontgenogram      ....    198 

264.  Fracture  of  head  of  radius.     Rontgenogram 199 

265.  Fracture  of  head  of  radius.     Rontgenogram 199 

266   and   267.     Gunstock   deformity   result  of   fracture   of   both   bones   of 

forearm  just  below  elbow 201 

268.  Structure  of  radius 204 

269.  Structure  of  ulna 204 

270.  Recent  fracture  of  both  bones  of  forearm 206 

271.  Another  view   of  same   case 207 

272  and  273.     Rontgenograms  of  same  case 207 

274  and  275.     Rontgenograms  of  same  case  after  operation      ....  208 

276.  Recent  fracture  of  both  bones  of  forearm 208 

277.  Recent  fracture  of  both  bones  of  the  forearm 209 

278.  Another   view  of  same   case 209 

279.  Reduction   of    same   case 210 

280.  Same  case  seen  from  ventral  surface  of  forearm 210 

281  and  282.  Rontgenograms  of  same  case  after  reduction  ....  211 
283  and  284.     Same  case  seen  after  splints  have  been  applied     .      .      .      .212 

2185  and  286.     Same  case  at  time  of  removal  of  splints 212 

287   and  288.     Fracture  of   radial   shaft 213 

289  and  290.     Opposite  arm  of  same  case  examined  for  comparison      .      .213 
291   and  292.     Rontgenograms  of  same  case  taken   after  reduction      .       .214 
293  and  294.     Rontgenograms  of  same  case  taken  after  second  reduction  214 
295  and  296.     Rontgenograms  of  same  case  taken  after  operation  and  in- 
ternal fixation 215 

297.  Fracture  of  both  bones  of  forearm  with  unusual  deformity  .  .  215 
298  and  299.  Two  views  of  recent  fracture  of  both  bones  of  the  forearm  216 
300.  Recent  fracture  of  both  bones  of  the  forearm  near  wrist  .  .  .216 
301   and  302.     Recent  fracture  of  both  bones  of  the  forearm  near  wrist 

with    slight   deformity 217 

303.  Fracture  of  radius  and  free  radial  styloid.  Rontgenogram  .  .  217 
304  and  305.     Rontgenogram  of  green-stick  fracture  of  ulna     ....   218 

306.  Testing   lateral   spring  in  bones   of  forearm 220 

307.  Recent  fracture  of  both  bones  of  forearm 223 

308.  Same  case.     Deformity  corrected  and  anterior  splint  applied      .      .   223 

309.  Same  case  showing  "cut-out"  in  ventral  splint 223 

310.  Same  case.     Dorsal  splint  applied 223 

311.  Splints  bandaged 223 

312.  Removal  of   dorsal   splint   for   inspection 224 

313  and  314.     Rontgenograms  of  fracture  of  both  bones  of  forearm  with 

overriding  deformity 227 

315  and  316.     Rontgenograms  of  same  case  after  operation  and  internal 

fixation 227 

317.  Slight  bowing  of  bones  of  forearm  following  imperfect  reduction      .  229 

318,  319   and  320.     Volkmann's  contracture 230 

321.     Fracture   of   both   bones   of   the   forearm   and   separation    of   lower 

ulnar    epiphysis 233 

322  and  323.     Rontgenograms  of  same  case 233 

324.  Fracture  and  separation   of  lower  ixlnar  epiphysis 234 

325.  Backward  dislocation  of  lower  end  of  ulna 238 


xviii  ILLUSTRATIONS 

FIG.  PAGE 

326,   327,   328,   329,   330   and   331.     Rijntgenograma   of  different  types   of 

fracture  of  lower  end  of  radius 243 

332,  333,  334.     Rontgenograms  of  '-Reversed  CoUes'  " 244 

335  and  336.     Fracture  of  lower  end  of  radius  produced  by  "auto-kick." 

Rontgcnogram 244 

337,  338  and  339.     Rontgenograms  of  Colles'  transverse  Colles'  fracture 

with     impaction 245 

340.     Fracture  of  lower  end  of  radius  produced  by  auto-kick.     Rontgcno- 
gram         246 

341    and    342.     Lateral    and    anteroposterior    views    of    Colles'    fracture 

with  slight  deformity.      Rontgenograms 247 

343.  Ri'.ntgenogram  of  comminuted  Colles'  fracture.  Rontgenogram  .  247 
344  and  345.  Rotgenogram  of  transverse  Colles'  fracture  with  impaction  248 
346  and  347.  Rontgenograms  of  oblique  Colles'  fracture  .  .  .  .  .  248 
348    and   349.     Rontgenograms   of   separation   of    lower    radial   epiphysis 

complicated  by  fracture 249 

350  and  351.  Separation  and  fracture  of  lower  radial  epiphysis  .  .  250 
352   and   353.     Separation   and  fracture  of   lower   radial  epiphysis     .      .   250 

354.  Recent   typical   Colles"   fracture 252 

355.  Recent  Colles'  fracture 252 

356.  Recent  Colles'  fracture  showing  radial  displacement  of  hand      .      .   253 

357  and  358.     Two  views  of  recent  Colles"  fracture 253 

359.     Recent   Colles'   fracture  showing  displacement  of  articular   surface  254 

360   and   361.     Two   views   of   recent   Colles'   fracture 254 

362   and   363.     Two  views  of  recent  Colles'  fracture 255 

364   and   365.     Two   views   of   recent   Colles'   fracture 255 

366  and  367.  Two  views  of  recent  oblique  Colles'  fracture  ....  256 
368  and  369.     Two  views  of  separation  of  lower  radial  epiphysis      .      .    258 

370.  Another  view   of   same   case 259 

371.  Recent  epiphyseal   separation   of  lower   end  of  radius      ....   259 

372.  Same   case   immediately   following  reduction 259 

373.  Radial  view  of  recent  Colles'  fracture 261 

374.  Ulnar  view  of  recent  Colles'  fracture 261 

375.  Same  case.     Ventral  view 261 

376.  Same  case.     Comparison   of  levels  of  two   styloids 261 

377.  Same  case.     Comparison   of  levels  of   two   styloids 261 

378  and  379.     Photographic  comparison  of  Colles'  fracture  and  backward 

dislocation  of  wrist 262 

380  and  381.     Radial  and  ulnar  views  of  recent  Colles'  fracture      .      .      .   263 
382  and  383.     Same  case  showing  two  methods  of  reducing  Colles'  frac- 
ture          264 

384.  Diagrams  illustrating  principles  involved  in  reducing  Colles'  frac- 

ture     264 

385.  Flat  ventral  splint 265 

386.  Flat  dorsal  splint 265 

387.  Flat  dorsal   splint   with   "ulnar   cut-out" 265 

388.  The  Walker   splint 266 

389.  Short  splints  and  adhesive;  for  Colles'  fracture 267 

390.  Proper  position  for  carrying  wrist  in  sling 267 

391.  Improper   position   for   carrying  wrist  in   sling 267 

392.  Rontgenogram  showing  radial  epiphysis  displaced  to  radial  side      .  270 

393.  Same    case    after    operation    and    internal    fixation 270 

394.  Colles'  fracture  24  hours  old.  Swelling  pronounced  ....  272 
395    and    396.     Old    Colles'    fracture    with    deformity 273 

397.  Old    Colles'    fracture    with    deformity 274 

398.  Loss   of    function    following    Colles'    fracture 274 

399.  Rontgenogram  of  same  case  showing  osteitis  of  carpus      ....  274 

400  and  401.     Contracture  following  Colles'  fracture 275 

402  and  403.     Ligaments  of  wrist 277 

404.     Rontgenogram  of  normal  bones  of  carpus  and  metacarpus   .  .  278 


ILLUSTRATIONS  XIX 
FIG.                                                                                                                                                                           I'^^OJ^ 

405.  Old    Colles'    and    anomalous    triangulare 279 

406.  Old    Colles'    and    anomalous    triangulare 279 

407.  Rontgenogram  of   anomalous  centrale 279 

408.  Rontgenogram  of  anomalous  space  corresponding  to  centrale     .      .  279 

409.  Old  united  fracture  of  scaphoid 280 

410.  Rontgenogram   of    fracture   of   semilunar 280 

411.  Rontgenogram   of    fractured    scaphoid 280 

412.  Rontgenogram  of  fractured  semilunar 281 

413    and   414.     Rontgenograms   of   luxated   semilunar 281 

415  and  416.     Old  Colles'  fracture  and  abnormal  condition  of  scaphoid. 

Rontgenogram         282 

417.  Rontgenogram  of  "Divided  Scaphoid" 283 

418.  Centrale  present  and  fused  with  os  magnum.     Rontgenogram      .      .  284 

419.  Rontgenogram   of   Colles'   fracture   and   fractured   trapezium      .      .  284 

420.  Severe  compound  fracture  dislocation  of  wrist 287 

421.  Old  injury  of  carpus 288 

422.  Rontgenogram    of    Bennett's    fracture 297 

423.  Rontgenogram   of   gunshot  fracture   of  metacarpal 298 

424.  Recent  Bennett's  fracture 299 

425.  426   and   427.     Recent   Bennett's   fracture 300 

428.  Recent  fracture   of   index  metacarpal 301 

429.  Fracture  of  metacarpals 301 

430.  Fracture    of    metacarpal 302 

431    and   432.     Recent   fracture   of   metacarpal 302 

433.  Old  fracture  of  fourth  metacarpal 303 

434,  435,   436  and  437.     Roller  bandage   dressing  for   fracture  of  meta- 

carpals            304 

438.  Compound   fracture   of   base   of   terminal    phalanx 308 

439.  Severe   compound   fracture   of   phalanges 308 

440.  Plaster   splint  for   thumb 309 

441.  Plaster  splint  for   finger 309 

442.  Board    splint    for    finger 310 

443  and  444.     Goldthwaite  tin  splint  for  fracture  of  thumb     ....  311 

445.  Tin  splint  applied  to  finger 311 

446.  Claw   nail   resulting   from   injury   to   finger 312 

447.  Dislocation  of  thumb 315 

448  and  449.     Compound  lateral  dislocation  of  thumb 315 

450.     Old  unreduced  lateral  dislocation  of  thumb 450 

451   and  452.     Recent  dislocation   of   finger 316 

453.  Ventral   dislocation  of   second  knuckle 316 

454.  Dorsal  dislocation  of  finger 316 

455.  Backward  luxation  of  second  joint  of  middle  finger 316 

456  and  457.     Sagittal  section  through  the  nasal  cavity 323 

4518.     Old  fracture  of  nasal  bones  with  lateral  displacement     ....  326 

459.  Old  fracture  of  nasal  bones  with  lateral  displacement      ....  326 

460.  Separation  and  lateral  displacement  of  lateral  and  septal  cartilages  326 

461.  Fracture   of   nasal   bones   and   partial   separation   of   cartilages     .  326 
462  and  463.     Destruction  of  nasal  bridge  from  syphilis 327 

464.  Falling  in  of  nasal  cartilages  in  old  case  of  syphilis     ....  328 

465.  Saddle  nose  in  hereditary  syphilis 328 

466.  Raising  the  depressed  nasal  bones 329 

467.  Packing  nasal  cavities 329 

468.  Asche  nasal  splints 329 

469.  Author's  moulded  dental  composition  splint     .      - 330 

470.  The  Cobb  nasal  splint 330 

471.  Relations  of  the  nasal,  lachrymal,  superior  maxilla  and  malar  bones  335 

472.  Zygomatic    arch    seen    from    below 335 

473.  Recent    fracture    of    left    malar    bone 337 

474.  Fracture  of  malar  bone  24  hours  after  injury 337 

475.  Fracture  of  malar  and  zygoma 338 


XX  ILLUSTRATIONS 

FIG.  PAGE 

47G.     Old  fracture  of  malar 341 

477   and  47S.     Old  fracture  of  malar   with  great  deformity  .341 

479.  Superior    maxilla 343 

480.  Fracture    of     superior     maxilla 34.5 

481    and   482.     Two   views    of    inferior    maxilla 348 

483.  Recent  fracture   of   inferior   maxilla   at   symphysis 351 

484.  Rontgenogram  of  same  case 351 

485.  Fracture  of  lower  jaw  just  anterior  to  rigiit  canine 352 

486.  Fracture  of  lower  jaw 352 

487.  Fracture  of  lower  jaw  between  canine  and  lateral  incisor      .  .  353 

488.  Fracture   of   lower  jaw   anterior   to   tirst   molar 354 

489.  Old   fracture   of   jaw   witii    deformity 355 

490.  Fracture  of  lower  jaw  behind  last  molar 355 

491.  Rontgenogram  of  same  case 356 

492  and  493.     Fourtailed  bandage  made  of  adhesive   .      .  ....  358 

494.  Interdental   splint   of  vulcanite 359 

495.  !Metal  dental  splint  with  arms  for  counter-pressure 361 

496.  Vulcanite  splint  with  arms  for  counter-pressure 361 

497.  Matas    splint   for   fracture    of   lower    jaw 362 

498  and  499.     Heath  metal  splint      .      .      .' 363 

500.  Edmund's   forceps   for   clamping  metal   splint  to  teeth      ....  364 

501.  Cast  aluminum   splint  cemented  to  teeth 364 

502.  Oliver's  method  of  wiring  the  lower  to  the  upjjcr  law  .  .  366 
503  and  504.  Manner  of  placing  loops  in  wiring  jaws  together  .  .  369 
505   and  506.     Wiring  jaws  together.     Four   points   of   fixation      .      .      .  361) 

507.     Jaws  wired   together   in   fracture  of  lower   jaw 370 

508  and  509.     Angle's  bands  and  bars 371 

510  and  511.     Angle's  bands  with  knobs 371 

512.  Scalp   wound   prepared   for    suture 387 

513.  Same  case.     Sutures  in  place 387 

514.  Same  case.     Bandaged 387 

515.  Interior    surface   of    right    half    of    skull 397 

516.  Interior  surface  of  right  half  of  base  of  skull 398 

517   and  518.     Craniometric  points  of   importance 400 

519.  Most    common    sites    of    meningeal    hemorrhage 400 

520.  Cortical  centers 400 

521.  Old  depressed  fracture  of  vault 413 

522.  Old  depressed  fracture  of  frontal   region 414 

523.  Old  depressed  fracture  of  skull  in  left  parietal  region      ....  414 

524.  Old  depressed   fracture   of   vault 415 

525.  Fracture  of  base  of  skull 415 

526.  Old   depressed   fracture  of   frontal  region 416 

527.  Severe   fracture   encircling   skull 416 

528.  Severe  compoiuid,  comminuted  fracture  of  vault 417 

529.  Severe   gunshot   fracture    of    skull 417 

530.  Rontgenogram   of  bullet  within   skull 418 

531.  Swelling  and  ecchymosis  about  eyes  suggestive  of  fracture  of  skull  419 

532.  Calvarium  of  patient  whq  previously  had  depressed  compound  frac- 

ture of  vault .419 

533  and  534.     Diagrams  indicating  steps  in  performing  osteoplastic  oper- 
ation on  skull 447 

535.  DeVilbiss   bone  cutting  forceps 448 

536.  Small  trephine     . 448 

537.  Relations  of   sternum 453 

538.  Rontgenogram  of  fracture  of  sternum 455 

539    and   540.     Reduction    of    fracture   of    sternum 457 

541.  Rontgenogram  of  fractures  of  third,  fourth,  fifth  and  sixth  ribs      .  460 

542.  Caving  in   of  chest 461 

543.  Fracture   and   displacement   of   costal   cartilage 461 

544.  Adhesive  plaster  strapping  for  fracture  of  ribs 463 


ILLUSTRATIONS  XXI 

FIG.  PAGE 

545.  RontgenooTani  of   fracture   of   cervical    sj)inc 466 

546.  Rontgenogram   of   fracturc-diHlocation   of  cervical    spine    ....  467 

547.  Rontgenogram  of  disloeati(jn  between  first  and  second  cervical  verte- 

brie 468 

548.  Rontgenogram   of   fracture   of  the   lower   dorsal   and   upper   lumbar 

vertebrae 460 

549.  550  and  551.     Two  views  and  section  of  old  fractured  spine     .      .      .  470 

552.  Rfmtgenogram   of  fracture  of  spine 471 

553.  Rontgenogram   of  fracture  of  body  of   fifth   lumbar   vertebra      .      .  472 

554  and  555.     Fracture  of  cervical  spine 474 

556   and   557.     Fracture  of   lower   dorsal   spine 475 

558.  Old  fracture  of  lower  dorsal  spine 477 

559.  Charco's    spine 477 

560.  Methods  of  wiring  spine 488 

561.  Incisions  used  in  performing  a  laminectomy  and   in   making  osteo- 

plastic flap 489 

562.  The  pelvis 492 

563.  Lateral  view  of  pelvis 493 

564.  Rontgenogram  of   fracture  of  pelvis  through  acetabulum      .      .      .  494 
565  and  566.     Fracture  of  ilium  and  tearing  away  of  abdominal  muscles  499 

567.  RontgenogTam   of   lateral   dislocation   of   coccyx 501 

568.  Double  plaster  spica  used  in  treatment  of  fracture  of  pelvis     .      .  508 

569.  The  ilio-femoral  or  Y-ligament  of  Bigelow 516 

570.  Iliac  dislocation  of  hip 517 

571.  Sciatic  dislocation  of  hip 517 

572.  Ilio-pectineal  dislocation   of  hip 518 

573.  Pubic  dislocation   of  hip 518 

574.  Obturator   or   thyroid   dislocation   of  hip 518 

575.  Perineal   dislocation    of   hip 518 

576.  Everted   dorsal   dislocation   of   hip ;      .      .      .      .  519 

577.  Attitude  in  dorsal  dislocation  of  hip 521 

578.  Attitude    in    anterior    dislocation    of    hip 521 

579    and   580.     Old   unreduced   dorsal   dislocation   of   hip 522 

581.  Reduction  of  dorsal  dislocation  of  hip 525 

582.  Stimson's  method  of  reducing  luxations  of  hip      .      .   -  .      .      .      .  526 

583.  Author's   modification    of    Bigelow's   method 526 

584.  Allis'  method  of  securing  pelvis  to  floor 527 

585  and  586.     Internal  structure  of  upper  end  of  femur 531 

587.     Nelaton's  line  and  Bryant's  triangle.     Diagram 534 

5i88.     Rontgenogram   of   impacted   fracture   of   femoral   neck      ....  535 

589.  Rontgenogram   of  old  ununited   fracture  of   femoral  neck     .      .      .  589 

590.  Rontgenogram  of  impacted  fracture  of  neck  of  femur      ....  589 

591.  Rontgenogram   of   fracture   of   femoral  neck 535 

592.  Rontgenogram    of   fracture   of   rim   of    acetabulum 536 

593.  Rontgenogram   of  fracture  of   great  trochanter 536 

594.  Rontgenogram  of  middle  of  femoral  neck 536 

595.  R6ntgenogi-am  of  base  of  femoral  neck  with  splitting  off  of  lesser 

trochanter          536 

596.  Impacted   fracture   of   neck    of   femur 538 

597.  Impacted   fracture   of  neck   of   femur 538 

598.  Fracture  of  right  femur  through  gxeat  trochanter 538 

599.  Fracture  of  femur   jvist  below  great  trochanter 538 

600.  Drawing  Nelaton's  line  on  patient 539 

601    and   602.     Measuring  length   of   lower   extremity 540 

603  and  604.     Diagrams  showing  effect  of  tipping  of  pelvis   .  .      .      .      .  541 

605.     Relaxation  of  fascia  lata  resvilt  of  raising  of  trochanter      .      .      .  541 

606  and  607.     Application  of  Buck's  extension 543 

608.  Weight  iised  with  Buck's  extension 543 

609.  Pulley  used  with  Buck's   extension 543 

610.  Long'T-splint 544 


XXll  ILLUSTRATIONS 

FIG.  P-^E 

611.  T-splint  applied  and  extension  in  use 544 

612.  Diagram  showing  principles  of  Ruth-Maxwell  method     ....   546 

613.  The  use  of  sand  hags  in  fracture  of  hip 546 

614.  Plaster  cast  applied  with  thigh  abducted 547 

615.  Plaster  cast  applied  with  hip  and  knee  semiflexed 548 

616.  Author's  screw  plates  for   internal  fixation  of  fracture  of  the  hip  530 

617.  Usual   sites   of   fracture   through   femoral   neck 551 

618.  Tendency  to  displacement  when  screw  is  used  in  fixation  of  liip      .   551 
610.     Author's    screw    plate    in    position 551 

620.  The  Thomas  hip  splint 553 

621.  The   ambulator}'   pneumatic   splint 554 

622.  Diagrams   illustrating  the  development  of  coxa  vara  after  Whit- 

man          556 

623.  Anterior  surface  of  femur 559 

624.  Posterior  surface  of  femur 559 

625.  Eontgenogram    of    transverse    fracture    of    femoral    shaft     .      .      .   560 

626.  Recent   fracture    of    riglit    femoral    shaft 561 

627.  Old   fracture   of   right    femoral    shaft 561 

628.  Recent  fracture  of  left  femoral  shaft 562 

629.  Recent  fracture  of  left  femoral  shaft 562 

630.  Correction  of  deformity  by  lateral  traction.     Diagram      ....   564 

631.  Adjustable  inclined  plane 564 

632   and   633.     Treatment   of   fracture   of   femoral   shaft    in    children   by 

suspension  565 

634.  The  Bradford  frame 565 

635.  The  Nichols   frame 569 

636.  Rontgenogram  of  double  spiral  fracture  of  shaft  of  femur      .      .      .   570 

637.  Rontgenogram  of  same  case  after  operation 570 

638.  Rontgenogram  of  same  case  two  years  after  operation      .      .      .      .571 

639.  Rontgenogram  of  same  case  six  years  after  operation      .      .      .      .571 

640.  Lateral  surface  of  lower  end  of  femur 575 

641.  Internal    structure    of    lower    end    of    femur 575 

642.  Rontgenogram   of  knee   showing  locations  of  epiphyseal   cartilages  576 

643.  Fracture  of  lower  end  of  femur  with  angular  deformity.     Rontgeno- 

gram         577 

644.  Supracondylar    fracture    with    pronounced    overriding.     Rontgeno- 

gram        577 

645.  Rontgenogram   of   old   displaced   fracture  with   refracture  through 

callus 577 

646.  Rontgenogram  of  fracture  of   femur  with  lateral  deformity      .      .   577 

647.  Fracture  of   lower   third   of   shaft   of   femur 578 

648.  Compound  comminuted  fracture  of  lower  end  of  femur      ....   578 

649.  Cabot  posterior  wire  hip  splint 580 

650.  Same,   bent   to   form    double   inclined   plane .580 

651.  Dupuy's  splint  used  as  double  inclined  plane 581 

652.  Dupuy's   splint 581 

653.  Adjustable   double   inclined   plane   fracture  box 582 

654.  Hogden's   splint 582 

655.  Adjustable   ambulatory   pneumatic   splint 585 

656  and  657.     Subluxation  of  knee  with  lateral  dislocation  of  patella  and 

displacement  of  semilunar  cartilage 589 

658.  Old  fracture  of  patella  with  separation  of  fragments     ....   596 

659.  Fracture  of  both  patellae 596 

660.  Dressing  for  fracture  of  patella 598 

661.  Ham  splint 599 

662.  Silver  wire  mattress  suture  of  patella 600 

663.  Internal  structure  of  patella 600 

664.  Rontgenogram  of  recent  fracture  of  patella 601 

665.  Same  case  after  operation 601 

666.  Wired  fracture  of  patella  three  years  after  operation      ....   603 


ILLUSTRATIONS  XXlll 

no.  PAGE 

667.  Wired   fracture   of   patella  two  years   after   operation      ....   603 

668.  Passive  motion  in  after-treatment  of  fracture  of  patella  ....   606 

669.  Diagram   of   normal   relations   of   patella 610 

670.  Diagram  of  lateral  dislocation  of  patella 610 

671.  Diagram  of  rotary  displacement  of  patella  and  lateral  dislocation 

"on   edge" 610 

672  and  673.     Ligaments  of  knee 614 

674.  Lateral  view  of  upper  epiphysis  of  tibia.  Rontgenogram  .  .  .  621 
675  and  676.  Anomalous  ossification  of  upper  end  of  tibia  ....  622 
677  and  678.     Rontgenogram  of  vertical  fracture  of  upper  end  of  tibia     .   623 

679.  Rontgenogram   of    fracture   of   upper   end   of   tibia 623 

680.  Rontgenogram  of  splitting  of  upper  end  of  tibia 623 

681.  Fracture  of  upper  end  of  tibia 625 

682.  Fracture  of  upper  end  of  right  tibia 626 

683.  Compound  fracture  of  both  bones  of  the  leg 636 

684.  Fracture  of  both  bones  of  the  leg 636 

685.  Compound  fracture  of  both  bones  of  the  leg 636 

686  and  687.     Fracture  of  both  bones  of  the  leg 637 

6818.     Fracture  of  both  bones  of  the  leg 638 

689.  Same  case  four  days  later  showing  blood  blebs 638 

690.  Green-stick  fracture  of  tibia  in  child 639 

691.  Compoimd  fracture  of  both  bones  of  leg 639 

692  and  693.     Fracture  of  tibia  near  ankle 640 

694  and  695.  Severe  compound  comminuted  fracture  of  both  bones  of  leg  641 
696  and  697.     Severe  compound  fracture  of  both  bones  of  the  leg      .      .    642 

698.  Folding  fracture-box  laid  open 643 

699.  Same  box  closed 643 

700.  Padding   used   with   fracture-box   and   method   of   holding   box   to- 

gether        643 

701  and  702.     Use  of  fracture-box  in  treating  fractures  of  the  leg     .      .  644 

703    and    704.     Short   Desault   splint 645 

705.  The    Cabot    posterior    wire    splint 646 

706.  The  N.   R.   Smith   splint 646 

707.  Elevated  fracture-box 647 

708.  Cradle  used  to  keep   bed  clothes   off   leg 647 

709  and  710.     Methods  of  securing  traction  on  fractures  near  the  ankle  647 

711.  Use  of  old  shoe  and  adhesive  in  obtaining  extension 647 

712.  Padding  to  relieve  heel  from  pressure 647 

713.  Plaster  of  Paris  splints  for  fracture  of  leg 648 

714.  Plaster   stirrup   for   fractures  of  the  leg 648 

715   and   716.     Two  views   of   comminuted   fractures   of  tibia  and  fibula 

near    ankle.     Rontgenograms 651 

717.  Rontgenogram  of  same  case  after  operation 652 

718.  Same  case.     Anterior  plaster  splint  removed  to  show  field  of  opera- 

tion   652 

719.  Ambulatory  pneumatic  splint  as  applied  to  fractures  of  the  leg     .  655 

720.  Old  fracture  of  tibia  and  fibula   with   discharging  sinus      .      .      .  656 

721.  Persistent  swelling  following  fracture  of  leg 656 

722.  723,  724  and  725.     Diagrams  illustrating  the  manner  in  which  the 

leg  is  thrown  "off  center"  when  union  occurs  with  deformity      .      .    657 
726  and  727.     Normal  relations  of  the  calcaneum,  astragalus  and  bones 

of  the  leg 660 

728.  Rontgenogram  of  normal  ankle  showing  epiphyses 661 

729.  Rontgenogram    of    Pott's    fracture 662 

730.  Rontgenogram  of  variant  of  Pott's  fracture 662 

731.  732  and  733.     Rontgenogram  of  Pott's  fracture 662 

734  to  737.     Rontgenogram  of  Pott's  fracture 663 

738.  Rontgenogram   of   old   Pott's   fracture 663 

739.  Rontgenogi-am  of  Pott's  fracture.     Lateral  view 663 

740.  Recent   Pott's   fracture   of   left   ankle 664 


XXIV  ILLUSTRATIONS 

FIG.  PAGE 

741   and  742.     Two  views  of  a  recent  Pott's  fracture fldf) 

743.  Another   view   of  same  case OfiCi 

744.  Eecent  Tott'p  fracture  seen   from  behind (i<i7 

745.  Same   case    after    deformity    lias   been    corrected (!()7 

746.  The  makino-  and   applicaticm  of  the   Dui)uytreii   splint      ....  (UiO 
747    and   748.     Stimson's   ])laster   splints ()7') 

749  and  7.'iO.     Riintgenograms  of  splitting  of  lower  end  of  tibia      .  .    CJ") 
751,    752    and    753.     Riintgenograms    of   fractures    of    internal    malh-oiiis 

at  different  levels '>7t) 

754.     Epiphyseal  separation   of  lower   end   of   tibia  complicated  l)y   frac- 
ture          07() 

755    and    756.     Sujiramalleolar    fracture 677 

757    and    758.     Supramalleolar    fracture 677 

750  and  760.     Supramalleolar  fracture  with  pronounced  deformity      .      .    670 

761    and   762.     Si)litting  of   lower   end   of   tibia 680 

763.     Old  fracture  of  both   bones  of  the  leg  with  backward  displacement  681 

764  and  765.     Ligaments  of  ankle 685 

766    and   767.     Inward    fracture-luxation    of    ankle 688 

768.     Anterior  dislocation  of  ankle 688 

760    and    770.     Anteroposterior    and    lateral    views    of    fracture-luxation 

of  astragalus.     Eontgenogram 692 

771.  Rontgenogram  of  lateral  dislocation  of  astragalus 693 

772.  Deformed   astragalus   removed  to   restore   function 697 

773    and   774.     Compound    subastragalar    luxation 700 

775.  Rontgenogram   of   fracture  of   calcaneum 704 

776.  Anomalous    trigonum 704 

777  and  778.     Rontgenograms  of  fractures  of  calcaneum 704 

779   and   780.     Crushing   injuries   of   tarsus 711 

781  and  782.     Rontgenograms  of  fractures  of  fifth  metatarsals      .      .      .715 

783.  Oblique  fracture  of  shaft  of  fifth  metatarsal 716 

784.  Rontgenogram  of  fracture  of  base  of  fifth  metatarsal      .      .      .      .716 

785.  Rontgenogram  of  compovmd  crushing  injury  of  metacarpus   .      .      .716 

786.  INIethod  of  detecting  fracture  in  the  metatarsal  bones      .      .      .      .717 

787.  Crushing   injviry   of   foot 717 

788.  Example    of    simple    transverse    fracture.     Rontgenogram      .      .      .    726 

789.  Example    of   multiple    fracture.     Rontgenogram 726 

790  and  791.     Surface  form  and  section  of  fracture  united  in  deformity  727 

792  and   793.     Rontgenograms    of    carcinoma   of   bone  with    spontaneous 

fracture        . 728 

794.  Carcinoma   of   lower    end   of   femur   with    extensive   destruction   of 

bone.      Rontgenogram 729 

795.  Syphilitic  dactylitis  with  spontaneous  fracture.     Rontgenogram      .  730 

796.  Spontaneous    fracture    following    osteo-sarcoma 730 

797.  Osteo-carcinoma   with    spontaneous   fracture.     Rontgenogram      .      .  731 

798.  Case  of  fetal  rickets  with  spontaneous  fracture.     Rontgenograms      .  732 
799  to  802.     Rontgenograms  of  lower  extremities  of  same  case      .      ,      .  733 

803.  The  Rose  portable  coil 738 

804.  The  Rose  portable  coil.     Larger   instrument 739 

805.  Special  type  of  Crook's  tube 740 

806.  Metallic  numbers  for  marking  X-ray  plates      .......  740 

807   and  808.     Diagram  illustrating  use  of  X-ray 742 

809,   810    and   811.     Diagram    illustrating  use   of   X-ray 743 

812.  Radio-chronometer 746 

813.  The  Bauer   qualimeter 746 

814.  Linear  fracture  of  upper  end  of  tibia 747 

815   and  816.     Antero-posterior  and  lateral  views  of  fracture  of  radius. 

Rontgenograms 748 

817  to  820.     Four  Rontgenograms  of  same  case  taken  from  different  po- 
sitions      749 

821  and  822.     Stereoscopic  Rontgenogram 751 


ILLUSTRATIONS  XXV 

FIG.  PAGE 

823.     Methods  of  using  wire  in  internal  fixation  of  fractures      ....  758 

824  and  825.     An  example  of  the  use  of  a  single  loop  of  wire      .      .      .  759 

826.  Instruments  serviceable  in  passing  wire  about  bone 760 

827.  The  Lane  bone  drill 760 

828  and  820.     Bone  forceps 761 

830.  Gerster's    turn-buckles 762 

831.  Appliance   for   holding   plate   in    position 763 

832.  Compound  fracture  of  both  bones  of  the  leg 764 

833.  Same  case  after  fixation  with  Freeman's  clamp 764 

834.  Set  of  Lane's  bone  plates 765 

385.     Comparison    of   wood    screw   and    Sherman's    "tap-screw"      .      .      .  766 

836.  Sherman's    tap-screws    and    screw    driver 76(i 

837.  Examples   of   broken    plates 767 

838    and   830.     Antero-posterior    and    lateral    views    of    fracture   of    hoth 

bones  of   leg.     Rontgenograms 7(J7 

840    and    841.     Antero-posterior    and    lateral    views    of    same    case    two 

years    later.     Plate   in    place.     Rontgenograms 767 

842.  Infected  tibia  from  which  Lane  plate  has  been  removed.     Rontgcn- 

ogram 76!) 

843.  Old  ununited  fracture  of  til)ial  shaft.     Diagram 778 

844.  Same,    after    ends   are   squared   and   medullary    cavity   reamed   out. 

Diagram ' 778 

845.  Same  with  medullary  dowel  graft  in  place.     Diagram 778 

846.  Making  saw  cuts  in  obtaining  medullary  graft.     Diagram    .      .      .  770 

847.  Removing   medullary   graft   with   chisel.     Diagram 770 

848.  Removing  medullary  graft  with  rotary  saw.     Diagram    ....  779 

849.  Inlay  graft  in  place.     Diagram 782 

850.  Method  of  securing  same  with  kangaroo  tendon.     Diagram   .      .      .  782 

851.  Motor  saw  equipment  including  twin  saws 783 

852.  Doweling  machine 783 

853.  First  step  in  Albee's  technique  in  recent  fractures.     Diagram     .      .  784 

854.  Same  with  "short  piece"  removed.     Diagram 784 

855.  Same  with  "long  piece"  held  in  place  by  bone  pegs.     Diagram   .      .  784 

856.  Upper  end  of  humerus  replaced  by  upper  end  of  fibula.     Diagram   .  786 

857.  Loss  of  tibial  shaft.     Diagram 787 

858.  (Same  after  upper  end  of  fibular  shaft  has  been  implanted  in  upper 

tibial   fragment.     Diagram 787 

859.  Same  after  operation  has  been  completed 787 

860.  Gangrene  of  leg  following  thrombosis 792 


PART  I. 
UPPER  EXTREMITY. 


FRACTURES  AND  DISLOCATIONS 


CHAPTER  I. 

FRACTURES  OF  THE  CLAVICLE  AND  INJURIES  TO 
THE  CLAVICULAR  ARTICULATIONS. 

The  clavicle  may  be  fractured  by  direct  or  indirect  violence,  or 
either  end  of  the  bone  may  be  dislocated.  The  early  ossification 
of  the  clavicle  accounts  for  the  frequency  with  which  it  is  fractured 
in  children,  and  the  fact  that  the  sterno-clavicular  ligaments 
extend  outward  onto  the  diaphysis,  explains  the  rarity  of  separation 
of  the  single  clavicular  epiphysis  situated  at  the  inner  end  of  the 
bone.  Dislocation  of  either  end  of  the  clavicle  is  rare  as  compared 
with  fracture.  Males  are  more  subject  to  injury  of  this  bone  and 
its  articulations  because  of  their  occupations,  and  heavier  muscula- 
ture. The  coraco-clavicular  ligaments  are  an  important  element 
in  determining  the  site  of  fracture  when  due  to  indirect  violence, 
and  in  limiting  the  displacement  in  both  fractures  and  dislocations. 
The  stability  of  either  end  of  the  clavicle  depends  on  ligaments, 
rather  than  the  conformation  of  the  articular  surfaces.  The 
acromial  end  is  dislocated  nearly  four  times  as  often  as  is  the 
sternal  end,  while  all  the  dislocations  of  the  clavicle  make  up  about 
four  percent  of  the  luxations  of  the  entire  body.  Dislocations  of 
both  ends  of  the  bone,  and  simultaneous  dislocations  of  both 
clavicles,  are  conditions  which  have  been  recorded,  though  they 
are  extremely  rare. 

Injuries  to  the  clavicle  and  its  articulations  will  be  taken  up  in 
the  following  order: 

Dislocation  of  the  sternal  end. 

Forward. 

Backward. 

Upward. 
Fracture  of  the  clavicle. 

3 


4  FRACTURES   AND    DISLOCATIONS 

Dislocation  of  the  acromial  end. 

Upward. 

Downward. 

Sub-eoracoid. 
Fracture  of  this  bone  is  so  common  and  dislocation  so  rare  that 
examination  of  the  ends  of  the  clavicle  is  often  neglected,  espe- 
cially in  the  presence  of  fracture.  The  fact  should  never  be  lost 
sight  of  that  two  or  more  lesions  may  be  present  at  the  same  time. 
A  systematic  examination  of  the  entire  region  should  be  made  in 
addition  to  determining  the  condition  of  the  bone  in  question. 
The  surgeon  should  remember  that  the  examination  is  not  neces- 
sarily concluded  with  the  finding  of  a  given  lesion ;  further  damage 
may  have  been  done  to  adjoining  bones  or  joints.  Particularly, 
care  should  be  exercised  in  examining  children  becaiLse  of  the  mild 
and  indefinite  character  of  the  symptoms  accompanying  the  frac- 
ture of  the  clavicle  in  the  early  years  of  life. 


CHAPTER  II. 

DISLOCATIONS  OF  THE  STERNAL  END  OF  THE 
CLAVICLE. 

Surgical  Anatomy. — The  articular  end  of  the  clavicle  is  much 
larger  than  the  articular  facet  on  the  sternum,  and  the  integrity  of 
the  joint  is  almost  entirely  dependent  on  the  ligaments  that  sur- 
round the  joint  and  bind  the  two  bones  together.  The  capsule  is 
attached  to  the  margins  of  the  two  articular  surfaces  and  com- 
pletely encloses  the  joint  cavity.  It  is  reinforced  in  front  and 
behind  by  the  anterior  and  posterior  sterno-clavicular  ligaments. 
To  the  inner  side  and  above,  it  is  overlaid  by  the  interclavicular 


Fig.  1. — Muscular  and  ligamentous  attachments  of  the  cla^vicle.  T.,  trapezius;  S.M., 
sterno-mastoid ;  D.,  deltoid;  P.M.,  pectoralis  major;  B.,  hiceps ;  R.,  rhomboid  ligament; 
C.C,  coraco-clavicular  ligament;  A.G.,  acromio-clavicular  ligament;  G.A.,  coraco-acromial 
ligament.  The  interclavicular  ligament  may  be  seen  attached  to  the  upper  aspect  of  the 
inner  end  of  the  bone. 

ligament  which  is  attached  to  both  clavicles.  Externally  the 
rhomboid  ligament,  extending  from  the  under  surface  of  the  clavicle 
to  the  cartilage  of  the  first  rib,  greatly  strengthens  the  articulation. 
This  ligament  is  in  relation  posteriorly  with  the  subclavian  vein. 
The  ends  of  the  bones  entering  into  this  articulation  are  very  poorly 
adapted  to  each  other  and  when  dislocation  takes  place  recurrence 
of  deformity  is  prompt,  unless  prevented  by  retentive  dressings. 
The  rhomboid  ligament  is  seldom  completely  torn  and  will  tend  to 
limit  the  displacement. 


6  ■  FRACTURES  AND    DISLOPATIONS 

Displacement  of  the  sternal  end  is  usually  the  result  of  indirect 
violence.  If  the  long  axis  of  the  clavicle  is  continued  inward  it 
will  pass  in  front  of  the  sternum,  and  accordingly  the  most  common 
type  of  luxation  of  the  sternal  end  is  forward.  The  displacement 
may  be  partial  or  complete  and  accordingly  the  condition  is  spoken 
of  as  either  a  luxation  or  a  subluxation.  Forced  backward  dis- 
placement of  the  shoulder  may  produce  a  luxation  of  tlio  inner 
end  of  the  clavicle  by  leverage  against  the  first  rib. 

Forward  dislocation  is  by  far  the  most  common  luxation  seen  at 
this  joint,  and  is  usually  the  result  of  the  shoulder  having  been 
driven  forcibly  backward  beyond  the  normal  limitation  of  motion. 
If  the  shoulder  be  carried  backward  the  inner  end  of  the  clavicle 
comes  in  contact  with  the  first  rib,  and  if  forced  still  further  back- 
ward this  contact  with  the  first  rib  acts  as  a  fulcrum  by  means  of 
which  the  inner  end  of  the  bone  is  torn  away  from  the  sternum  and 
displaced  forward.  This  mechanism  seems  to  be  the  usual  cause 
of  displacement,  though  there  are  some  instances  in  which  the 
condition  has  taken  place  gradually  and  has  apparently  been  the 
result  of  a  general  relaxation  of  the  ligaments  about  the  joint. 

Backward  luxations  are  not  as  common  as  the  type  just  descri])ed, 
though  they  are  next  in  order  of  frequency.  They  are  usually  the 
result  of  violence  which  forces  the  shoulder  forward  and  inward, 
though  they  are  sometimes  caused  by  a  direct  force  which  drives 
the  inner  end  of  the  clavicle  backward.  The  trachea,  oesophagus 
and  the  large  vessels  of  the  neck  lie  behind  the  inner  end  of  the 
clavicle,  and  when  a  posterior  displacement  occurs  any  or  all  of 
these  structures  may  be  pressed  upon. 

Upward  luxation  of  the  sternal  end  of  the  clavicle  is  extremely 
rare  and  is  usually  the  result  of  violence  which  depresses  the 
shoulder.  The  ligaments  are  more  or  less  torn  according  to  the 
severity  of  the  causative  trauma.  Luxations  of  the  inner  end  of 
the  clavicle  are  rare,  as  compared  with  fractures  of  the  clavicle. 

Symptoms. — Pain  is  more  or  less  pronounced  at  the  site  of  the 
lesion  and  is  increased  with  motion  of  the  shoulder.  Loss  of 
function  varies  with  the  completeness  of  the  dislocation  and  the 
amount  of  pain  suffered  by  the  patient.  There  is  more  or  less 
swelling  about  the  inner  end  of  the  bone.  The  deformity  varies 
with  the  direction  of  the  luxation. 

In  forward  luxations  the  inner  end  of  the  bone  is  more  prominent 
than    normal   and   is   often    found   displaced    downward    onto   the 


DISLOCATIONS   OF   STERNAL   END   OF    CLAVICLE  7 

anterior  surface  of  the  sternum,  as  well  as  forward.  The  lowered 
position  of  the  inner  end  of  the  bone  changes  the  axis  of  the  clavicle, 
which  deformity  can  often  be  recognized  by  inspection  alone. 

In  backward  luxations  it  will  be  noted  that  the  normal  promi- 
nence of  the  inner  end  of  the  clavicle  is  absent,  and  the  axis  of  the 
bone  is  changed.  Palpation  of  the  shaft  of  the  clavicle  will  dis- 
close the  altered  position.  Passive  congestion  of  the  face  on  the 
side  of  the  luxation  may  be  present,  and  in  severe  cases  cyanosis 
may  be  pronounced.  Dysphagia  and  dyspnoea  are  not  uncommon. 
The  acuteness  of  these  symptoms  usually  subsides  even  though  the 
displacement  be  allowed  to  go  uncorrected.  There  is  no  reported 
case  of  permanent  injury  to  the  structures  thus  pressed  upon  and 
accordingly  these  symptoms  are  not  alarming.  The  shoulder  is 
displaced  downward  and  forward  and  is  a  little  nearer  the  thorax 
than  normal.  This  displacement  is  often  slight  and  if  the  shoulder 
is  not  compared  with  the  opposite  side  the  deformity  may  go 
unrecognized. 

In  upivard  luxations  there  is  a  variable  amount  of  disturbance 
in  function  and  pain  at  the  seat  of  injury.  Inspection  and  palpa- 
tion will  show  the  change  in  the  axis  of  the  bone  and  the  upward 
displacement  of  the  inner  end.  The  inner  end  of  the  bone  is 
abnormally  mobile. 

Diagnosis. — The  clavicle  is  subcutaneous  throughout  and  the 
sternal  notch  may  be  palpated  without  difficulty.  Accordingly 
displacements  of  the  inner  end  of  the  bone  are  easily  determined. 
Differentiation  of  fractures  of  the  clavicle  from  luxations  of  the 
inner  end  presents  no  particular  difficulty  unless  the  swelling  is 
pronounced.  In  fractures  of  this  bone  crepitus  is  almost  invariably 
distinct,  and  the  absence  of  this  symptom  in  luxations  is  significant. 
The  distance  between  the  tip  of  the  acromion  and  the  middle  of  the 
suprasternal  notch  is  lessened  in  both  fractures  and  luxations. 
Dislocations  of  the  inner  end  of  the  clavicle  are  not  infrequently 
overlooked  because  of  associated  lesions  which  are  more  evident. 
The  X-ray  is  of  value  as  a  routine  measure  but  is  seldom  necessary 
to  establish  the  diagnosis. 

Treatment. — Keduction  is,  as  a  rule,  easily  accomplished  but  it 
is  usually  a  difficult  matter  to  retain  the  articular  surfaces  in  their 
proper  relations.  Certain  positions  are  known  to  be  favorable  in 
the  prevention  of  the  recurrence  of  deformity  but  the  surgeon 
should  determine  for  himself  in  each  and  every  case  just  what 


b  FRACTrRKS    AXn    niST.OrATTONS 

position  is  most  favoi';il)lf  in  holdinii'  the  aiiictihif  surfju^os  in 
apposition. 

In  forward  fu.niUcHs  the  condition  is  easily  ]-eco«;niz('(l  and  tlicfe 
is  little  (liftii'iilty  in  rcdticing  the  displacement.  Ontward  and 
upward  traction  on  the  shoulder  with  direct  pressure  on  the  end 
of  the  bone  will  usually  be  all  that  is  necessary  to  effect  reduction. 
The  displacing  action  resulting  from  contact  between  the  clavicle 
and  first  rib  is  avoided  by  preventing  extreme  backward  displace- 
ment of  the  shoulder  during  the  after-treatment.  Any  form  of 
dressing  wliich  will  properly  immobilize  the  shoulder  without 
carrying  it  too  far  backward  will  accomplish  the  desired  result. 
"When  the  ligamentous  tearing  has  been  extensive  it  may  be  neces- 
sary to  employ  some  form  of  dressing  which  will  support  the 
weight  of  the  upper  extremity  and  overcome  the  action  of  the 
muscles  which  pull  the  shoulder  downward,  forward  and  inward. 
In  accomplishing  this  purpose  care  should  be  exercised  not  to  pull 
the  shoulder  too  far  backward.  A  figure-of-eight  of  both  shoulders 
with  the  turns  passing  in  front  of  the  chest,  and  another  figure-of- 
eight  with  the  turns  across  the  back  will  fix  the  shoulder  sufficiently 
for  all  practical  purposes.  A  plaster  of  Paris  spica  will  immobilize 
the  shoulder  very  perfectly  but  is  seldom  necessary.  It  is  often 
advisable  to  employ  direct  pressure  over  the  sternal  end  of  the 
clavicle  by  means  of  pads  and  strips  of  adhesive  plaster.  When 
pressure  is  used  in  this  way  it  should  be  remembered  that  the  end 
of  the  bone  is  subcutaneous  and  that  sloughing  of  the  skin  may 
follow  if  the  pressure  is  too  severe  or  too  long  continued.  It  is 
probably  better  to  exert  the  pressure  over  the  inner  two  inches 
of  the  shaft  rather  than  directly  over  the  end  of  the  bone.  The 
necessity  for  direct  pressure  will  depend  on  the  tendencj^  to  recur- 
rence of  deformity  after  the  shoulder  has  been  fixed.  There  is 
probably  no  dressing  which  will  perfectly  fill  all  requirements  in 
all  instances.  Each  case  must  be  considered  by  itself  and  the  par- 
ticular dressing  employed  is  of  secondary  moment,  provided  the 
shoulder  is  immobilized  with  the  luxation  in  reduction  and  in  a 
position  showing  the  least  tendency  to  the  recurrence  of  deformity. 
It  will  be  found  practically  impossible  to  entirely  correct  the 
anterior  displacement,  but  absolute  reduction  is  not  essential  to 
complete  restoration  of  fnnetion,  and  the  slight  deformity  remain- 
ing is  of  little  moment. 

Young  W'Omen  may  be  desirous,  for  cosmetic  reasons,  of  securing 


DISLOCATIONS    OF   STERNAL   END   OP    CLAVICLE  9 

as  perfect  reduction  as  possible,  and  in  such  instances  the  shoulder 
should  be  fixed  and  the  displacement  treated  in  the  recumbent 
position  for  a  period  varying  from  ten  days  to  two  weeks. 

In  backward  dislocalions  of  tlie  inner  end  of  the  clavicle  reduction 
is  accomplished  by  traction  upward,  outward  and  backward,  and 
is,  as  a  rule,  attended  by  little  difficulty.  If  additional  manipula- 
tion is  required  the  clavicle  may  be  grasped  in  its  middle  third, 
where  it  is  free  from  heavy  muscular  attachment,  and  direct  trac- 
tion made  to  replace  the  inner  end  of  the  bone  as  the  shoulder  is 
being  pulled  outward  and  backward.  Reduction  is  much  more 
easily  maintained  than  in  the  forward  variety,  though  the  shoulder 
should  be  immobilized  and  the  case  kept  under  observation  as  in 
forward  dislocations.  The  shoulder  may  be  immobilized  by  the 
double  figure-of-eight  as  already  described,  or  the  Velpeau  or  Sayre 
dressing  may  be  employed.  (See  Figs.  30  to  35.)  Direct 
pressure  over  the  inner  end  of  the  bone  is  seldom  required  in  this 
form  of  luxation. 

In  upward  luxation  of  the  sterno-clavicular  joint,  reduction  is 
accomplished  by  outward  traction  on  the  shoulder  accompanied  by 
direct  downward  pressure  on  the  inner  end  of  the  clavicle.  INIain- 
taining  the  end  of  the  bone  in  proper  position  is  attended  with 
difficulty  here,  as  in  other  types  of  luxation  at  this  joint.  The 
shoulder  should  be  immobilized  and  the  arm  supported  to  prevent 
downward  displacement.  If  there  is  much  displacement  of  the 
clavicle  it  may  be  w^ell  to  place  a  pad  in  the  axilla,  and  bind  the 
arm  to  the  side  to  maintain  the  proper  distance  of  the  shoulder 
from  the  thorax.  The  principles  involved  in  the  treatment  of  this 
dislocation  are  similar  to  those  already  described  in  the  two  pre- 
ceding types  of  luxation. 

Operative  Treatment. — Operative  intervention  is,  as  a  rule, 
indicated  only  in  old  cases  with  loss  of  function,  and  in  cases  of 
recurrent  dislocation  which  have  not  responded  to  non-operative 
measures.  Proper  reduction  can  almost  invariably  be  had  in  recent 
cases  by  proper  fixation,  but  should  recurrence  of  deformity  take 
place  in  spite  of  appropriate  dressings,  it  may  be  advisable  to 
expose  the  end  of  the  bone  and  secure  it  in  position  with  suture. 

An  incision  parallel  to  the  clavicle  is  made  exposing  the  parts; 
the  end  of  the  clavicle  is  then  dissected  out  from  the  fibrous  tissue 
which  surrounds  it  in  its  displaced  position  in  old  cases.  It  is 
then  returned  to  its  proper  relation  with  the  sternum  and  fixed  in 


10  FRACTURES   AND   DISLOCATIONS 

position.  It  may  be  possible  in  some  eases  to  repair  tlie  ligaments 
sufficiently  to  retain  the  end  of  the  bone  in  place.  In  other 
instances  it  may  be  necessary  to  drill  holes  in  the  end  of  the  clavicle 
and  the  upper  end  of  the  sternum  and  prevent  recurrence  by  some 
form  of  suture  material,  either  absorbable  or  otherwise.  The  rela- 
tion of  the  great  vessels  of  the  neck  should  be  kept  in  mind  when 
operating  in  this  region.  In  cases  of  recurrent  or  habitual  disloca- 
tion a  repair  of  the  ligaments  will  frequently  be  all  that  is  required. 
The  same  results  have  been  obtained  by  the  repeated  injection  of 
small  quantities  of  alcohol  in  the  region  of  the  anterior  sterno- 
clavicular ligament,  thus  producing  inflammatory  reaction  and 
secondary  fibrosis.  Resection  of  the  articular  end  of  the  clavicle, 
with  the  subsequent  formation  of  a  false  joint,  is  a  method  which 
has  been  followed  by  excellent  results  in  habitual  luxations. 

Operative  treatment  is  rarely  indicated  in  backward  or  upward 
luxations,  but  should  the  necessity  arise  for  open  treatment  in 
either  type  the  principles  will  be  the  same  as  already  given. 

After-Treatment. — In  simple  cases  the  retentive  dressings  may 
be  dispensed  with  at  the  end  of  a  month,  and  pressure  over  the 
sternal  end  is  seldom  of  use  after  ten  days  to  two  weeks.  During 
the  progress  of  the  case  the  dressings  should  be  examined  frequently 
to  correct  alteration  in  position,  and  when  pressure  is  employed 
the  parts  should  be  carefully  watched  so  that  irritation  of  the 
skin  may  be  immediately  detected  if  it  appears.  Activities  sub- 
jecting the  articulation  to  much  strain  should  be  avoided  for 
another  month  to  six  weeks  following  removal  of  all  dressings, 
"When  these  simple  details  are  followed  the  patient  will  almost 
invariably  make  a  perfect  functional  recovery,  though  there  is 
usually  some  prominence  remaining  at  the  site  of  the  dislocation. 
The  after-treatment  is  the  same  in  all  forms  of  luxation  of  the 
sterno-clavicular  joint. 

Prognosis. — With  proper  reduction  and  immobilization  restora- 
tion of  function  should  be  practically  complete.  If  the  end  of 
the  bone  is  allowed  to  remain  in  displacement  there  will  be  more 
or  less  loss  of  function.  If  strain  is  placed  on  the  joint  too  soon 
following  the  initial  luxation  the  condition  may  become  recurrent. 


CHAPTER  III. 

FRACTURES  OF  THE  CLAVICLE. 

Surgical  Anatomy. — The  clavicle  is  the  most  frequently  broken 
single  bone  in  the  entire  body,  and  this  fact  renders  a  study  of  its 
anatomy  particularly  advisable.  This  fracture  is  especially  com- 
mon in  children.  The  clavicle  is  the  only  bone  connecting  the  upper 
extremity  with  the  trunk,  and  its  position  is  quite  superficial. 
These  two  facts  expose  the  bone  to  fracture,  both  from  direct  and 
indirect  violence.  The  most  common  fracture  is  the  result  of 
indirect  violence  and  the  break  is  usually  situated  at  or  near  the 
junction  of  the  outer  and  middle  thirds  where  the  two  curves 
of  the  shaft  meet,  and  the  bone  changes  in  form  from  "prismatic" 
to  "flat." 

The  shaft  of  the  clavicle  is  well  ossified  before  birth,  and  the  bone 
has  but  one  epiphysis  which  is  situated  at  the  sternal  end.  This 
single  epiphysis  begins  to  ossify  at  about  the  eighteenth  year  and 
joins  the  shaft  during  the  twenty-fifth  year.  The  ligaments  of  the 
sterno-clavicular  articulation  extend  beyond  the  epiphysis  and  are 
attached  to  the  shaft  of  the  bone  so  that  epiphyseal  separations  are 
almost  never  seen. 

The  clavicle  is  situated  in  a  muscular  plane  which  should  be 
understood  to  appreciate  the  displacements  which  take  place  when 
fracture  occurs.  On  the  inner  end  of  the  bone  is  attached  the 
clavicular  origin  of  the  sterno-mastoid  above,  while  opposite  it  on 
the  anterior  and  lower  aspect  of  the  bone  is  attached  the  clavicular 
origin  of  the  pectoralis  major.  In  the  presence  of  fracture  in  the 
usual  site,  it  might  seem  that  these  muscles  would  counteract  each 
other,  but  if  the  direction  of  the  fibres  of  these  two  muscles  is 
observed  it  will  be  noted  that  those  of  the  pectoralis  approach  the 
bone  at  an  acute  angle,  while  the  clavicular  head  of  the  sterno- 
mastoid  is  placed  at  nearly  right  angles  with  the  shaft.  This  gives 
the  sterno-mastoid  the  mechanical  advantage,  and  accordingly  the 
inner  fragment  is  displaced  upward.  The  subclavius  is  attached 
to  the  inferior  surface  of  the  shaft,  in  its  middle  third,  and  when 

11 


12  KKAITI'KKS    AND    OISLOCATIONS 

the  bone  is  lirokcn  and  depressed  against  the  first  rib  and  the 
structures  passing  into  the  axilla,  it  acts,  to  some  extent,  as  a 
cushion.  To  the  anterior  border  of  the  outer  third  is  attached  the 
deltoid,  and  on  the  posterior  border  of  the  same  corresponding 
portion  of  bone  is  found  the  clavicular  insertion  of  the  trapezius. 
These  two  muscles  about  balance  each  other  and  are  seldom  respon- 
sible for  displacement  of  fragments.  The  ligaments  of  the 
clavicle  play  an  important  part  in  preventing  and  limiting  dis- 
placement of  the   fi-agments.     The   rlioniljoid  ligament  is  a  heavy 


Fig.    2.  Fig.    3.  Fig.    4.  Fis.    5. 

Figs.  2  and  3  show  the  superior  surfaces  of  the  riglit  clavicle.  Dotted  lines  indicate 
the  margins  of  muscular  and  ligamentous  attachments. 

Figs.  4  and  5  show  the  internal  structure  of  the  same  bone.  Note  the  preponderance 
of   compact  tissue   in   the   shaft   and  region  corresponding  to  the  oblique   line. 

structure  Avhich  passes  from  the  first  costal  cartilage  to  the  under 
surface  of  the  inner  end  of  the  clavicle.  The  sterno-mastoid  usually 
displaces  the  inner  fragment  upward  until  this  ligament  becomes 
taut,  when  further  deformity  is  checked.  When  the  fracture  lies 
internal  to  the  coraco-clavicular  (eoronoid  and  trapezoid)  ligament 
the  inner  fragment  is  free  to  move  upward,  while  the  outer  frag- 
ment falls  downward,  inward  and  forward  with  the  shoulder. 
"When  the  fract^^re  passes  through  this  ligament  both  fragments 
remain  attached  to  the  coracoid  and  displacement  is  slight  or 
absent.  Fractures  of  the  clavicle  between  the  coraco-clavicular  and 
acromio-clavicular  ligaments  are  usually  not  accompanied  by  much 
deformity. 


FRACTURES   OP    THE    CLAVICLE 


13 


It  is  not  often  necessary  to  operate  on  the  clavicle,  but  when  the 
occasion  does  arise  the  surgeon  should  appreciate  the  internal 
structure  of  the  bone.  Figs.  4  and  5  show  a  horizontal  section 
of  the  bone.  The  clavicle  is  composed  largely  of  compact  tissue, 
the  cancellous  bone  being  confined  to  the  extremities.     The  compact 


Fig.    6. — Diagram   showing  the   relations   of   tlie   brachial   plexus   to   the   first   rib    and 
clavicle.      Section  of  clavicle  removed. 

tissue  is  particularly  heayy  in  the  region  of  the  oblique  line  where 
the  coraco-clavicular  ligaments  are  attached. 

The  clavicle  is  subcutaneous  throughout  and  easily  palpated.     It 
should  be  noted  that  the  acromion  stands  directly  external  to  the 


Fig.    7. — Fracture  of  the  clavicle  with  overriding  deformity  in   a  child. 

outer  end  of  the  bone,  as  well  as  behind  it.  The  rounding  of  the 
outer  aspect  of  the  shoulder  is  caused  by  the  head  of  the  humerus 
beneath  the  deltoid,  and  not  by  either  clavicle  or  acromion. 

Any  portion  of  the  clavicle  may  be  broken,  but  by  far  the  most 
common  site  of  fracture  is  in  the  outer  end  of  the  middle  third  and 


14 


FRACTURES   AND   DISLOCATIONS 


is  decidedly  oblique.  Fracture  iu  this  region  is  usually  the  result 
of  indirect  violence  and  is  almost  always  produced  by  a  fall  on  the 
shoulder;     Trauma  sustained  in  this  way  more  often  produces  a 


Fig.   9. — Green-stick  fracture  of  the  clavicle. 


dislocation  of  the  shoulder  in  adults,  while  in  children  fracture  is 
more  common  because  the  clavicle  is  relatively  weaker.  Incom- 
plete  fracture  is  common  in   children.     Fractures  in   either   the 


FRACTURES   OP    THE    CLAVICLE 


15 


inner  or  outer  third  are  comparatively  rare  and  usually  the  result 
of  direct  violence.  Muscular  action  is  sometimes,  though  rarely, 
responsible  for  fracture  of  the  clavicle. 

It  should  be  remembered  that  fracture  internal  to  the  coraco- 
clavicular  ligament  completely  destroys  all  bony  and  ligamentous 


4PI 


Fig.   10. — Fracture  of  the  middle  third  of  the  clavicle  with  the  usual  deformity — up- 
ward  displacement  of   the   inner   fragment. 


Fig.  11. — Fracture  of  the  clavicle  with  the  usual  deformity. 


connection  between  the  scapula  and  sternum,  but  when  the  break 
occurs  through,  or  external  to,  this  ligament,  a  heavy  bond  is  main- 
tained between  the  inner  fragment  and  the  shoulder  blade. 
Simultaneous  fracture  of  both  clavicles  is  occasionally  seen  as  a 
result  of  transverse  crushes  of  the  shoulders. 

Symptoms. — The  patient  complains  of  pain  immediately  follow- 
ing the  accident,  and  there  is  almost  complete  loss  of  function 


16 


FRACTURES   AND   DISLOCATIONS 


Fig.   12. — Coiuniimited  fractuit  of  the  outer  end  of  llie  clavicle    (rare). 


-Coniminuled    fracture    of    tlie    clavicle    with    ovei-ridiii^'. 


as  a  result  of  pain  and  of  the  disturbed  mechanism  of  the  shoulder. 
Swelling  usually  develops  within  a  few  hours  and  obliterates  the 
supra-  and  infra-clavicular  fossae.  The  surgeon  can  hardly  fail 
to  recognize  the  obliteration  of  these  fossfe  if  the  opposite  shoulder 
is  inspected  and  compared.  If  the  inner  fragment  is  free  of  the 
coraco-clavicular  ligament  the  deformity  will  be  so  pronounced  that 
the  nature  of  the  injury  should  be  recognized  by  inspection  alone. 
The  shoulder  is  displaced  inward,  forward  and  downward,  the 
injured  member  is  supported  with  the  opposite  hand  and  the  head 


FRACTURES   OF    THE    CLAVICLE 


17 


is  inclined  to  the  injured  side  to  relax  tlie  pull  of  the  stenio-inastoid. 
The  patient  is  unable  to  draw  the  shoukhu-  forward,  as  sliown  in 
normal  cases  in  Figs.  27  and  28.     The  inner  fragment  is  usually 


Fig.  14. — Fracture  of  the  right  clavicle  about  twenty  minutes  after  the  accident. 
The  injury  was  sustained  by  a  fall  on  the  shoulder.  Note  the  swelling  in  the  region  of 
the  fracture  and  the  slight' falling  of  the  shoulder.  The  manner  in  which  the  patient 
grasps  and  supports  the  injured  member  is  characteristic.  If  need  be  the  diagnosis 
might  be  made  by  inspection  alone.  Palpation  reveals  abnormal  mobility  and  crepitus 
at  the  site  of  fracture. 


F\e:.    15. 


Fig.    16. 


Figs.  15  and  16. — Front  and  side  views  of  fracture  of  the  clavicle  with  moderate 
deformity.  Note  the  prominence  produced  by  the  outer  end  of  the  inner  fragment. 
Photograplis  taken   about  thirty   minutes   following   the   accident. 

displaced  upward  and  can,  as  a  rule,  be  palpated  and  moved 
without  difficulty.  The  nearer  the  fracture  is  situated  to  the  inner 
third  of  the  bone  the  more  pronounced  will  be  the  angle  of  upward 


18 


FRACTURES   AND   DISLOCATIONS 


displacement.  The  distance  between  the  supra-sternal  notch  and 
the  acromion  process  is  decreased  on  the  injured  side;  in  other 
words  the  shoulder  is  shortened.     When  the  fracture  lies  through 


Figs.  17  and  18. — Fracture  of  the  right  clavicle  at  about  its  middle.  Note  the 
promineuce  of  the  outer  end  of  the  inner  fragment.  Photographs  taken  about  twenty 
minutes  following  the  accident. 


Fia; 


Fig.   20. 


Figs.  19  and  20. — Fracture  of  left  clavicle  about  twenty-four  hours  following  in- 
jury. Note  the  falling  of  the  injured  shoulder  and  the  swelling  which  obliterates  the 
supra-  and  infra-clavicular  fossag.  The  side  view  shows  the  forward  displacement  of  the 
shoulder   which   is   common    in   fractures   of   this   bone. 


or  external  to  the  coraco-clavicular  ligament  the  deformity  will 
usually  be  too  slight  to  recognize  by  inspection,  and  the  patient  will 


FRACTURES   OF    THE   CLAVICI;E 


19 


not  show  the  usual  anxiety  in  supporting  the  injured  member. 
Pain,  local  tenderness  and  less  pronounced  loss  of  function  will, 
however,  be  present.  If  the  surgeon  fixes  the  shoulder  with  one 
hand,  the  fingers  of  the  opposite  hand  will  detect  abnormal  mobility 


Fig.   21. 


Figs.  21  and  22. — Fracture  of  the  left  clavicle  with  pronounced  upward  displace- 
ment of  the  inner  fragment  which  is  not  bound  down  by  the  coraco-clavicular  ligament. 
The  following  points  are  significant  in  making  a  diagnosis  from  inspection  alone : 
Contour  of  shoulder  normal,  axis  of  arm  normal,  shoulder  as  a  whole  slightly  lowered 
and  patient  grasps  forearm.  Deformity  of  clavicle  plainly  visible  as  well  as  palpable. 
Photographs  taken  a  few  minutes  following  the  accident. 


Fig.   23. 


Figs.  23  and  24. — Delayed  union  of  clavicle  due  to  poor  approximation  of  frag- 
ments. The  inner  fragment  is  above  and  anterior  to  the  external  fragment.  This  de- 
formity is  chiefly  the  result  of  the  action  of  the  clavicular  attachment  of  the  sterno- 
mastoid.  Fracture  nearer  the  median  line  than  visual.  Injury  the  result  of  direct 
violence.     Patient  first  seen  by   author  six  weeks   after  the   accident. 

by  alternate  forward  and  backward  pressure  on  the  clavicle,  in 
the  region  of  the  fracture.  The  middle  third  of  the  clavicle  is  free 
from  heavy  muscular  attachments  and  can  be  grasped  without  diffi- 
culty  in  testing  the   integrity   of  the   bone.     When   the   normal 


20 


FRACTURES   AND    DISLOCATIONS 


Fig.  25. — Fracture  of  the  left  chivicle  in  an  elderly  woman  some  days  following 
the  accident.  Note  the  ecchyniosis  in  the  region  of  the  fracture  and  the  obliteration 
by  swelling  of  the  supra-  and  infra-clavicular  fossie.  Falling  of  shoulder  not  apparent 
because  elbow  is  supported   by   the   arm   of  the   chair. 


Fig.  26. — Fracture  of  right  clavicle  with  i)r(jiiounced  deformity  following  improper 
treatment.  This  case  (according  to  the  history  given  by  the  patient)  was  treated  by 
means  of  a  plaster  east  of  the  shoulder  and  the  deformity  recognized  only  when  the 
dressing  wa.s  removed  some  weeks  later.  Function  of  shoulder  much  impaired  and 
symptoms  of  brachial  ple.xus  irritation  present.  This  condition  is  a  striking  example 
of  what  may  follow  treatment  which  is  not  based  on  proper  principles. 


FRACTURES    OF    TflR    OT.AVTOI^E 


21 


shoulder  is  thrown  forward  this  middle  third  stands  out  promi- 
nently as  shown  in  Figs.  27  and  28. 

Ecchymosis  usually  develops  within  the  first  day  or  two  and  is 
almost  pathognomonic  of  fracture. 

In  children  the  fracture  is  often  incomplete  and  the  symptoms 
are  much  less  pronounced.  Local  tenderness  and  pain  are  present 
but  the  child  may  not  show  any  perceptible  disturbance  in  the  use 
of  the  arm  and  hand.     More  commonly,  however,  there  is  a  disin- 


Fig.    28. 

Figs.  27  and  28. — These  two  pictures  were  taken  to  demonstrate  the  manner  in 
which  the  outlines  of  the  clavicles  may  be  brought  out  by  throwing  the  shoulders  for- 
ward. This  movement  not  only  brings  out  the  outline  of  the  bone  but  shows  whether 
or  not  the  clavicle  is  properly  performing  its  function.  If  the  clavicle  is  fractured  the 
action  of  the  shoulder  will  be  quite  different  when  the  patient  is  requested  to  throw 
the  shoulder  forward.  In  adipose  and  well-muscled  persons  it  is  more  difficult  to  see 
the  outline  of  the  clavicle,  yet  the  signs  and  symptoms  of  fracture  are  almost  always 
suiificiently  pronounced  to  form  a  diagnosis  if  the  examiner  is  observant  and  systematic. 


clination  to  use  the  hand  of  the  injured  side  and  the  patient  will 
cry  out  when  the  arm,  forearm  or  shoulder  is  manipulated.  Local 
swelling  is  usually  present.  When  the  fracture  is  complete  the 
symptoms  will  be  more  pronounced  though  deformity  is  almost 
always  slight  in  children. 

Fracture  of  the  clavicle  is  rarely  compound  and  injury  to  the 
structures  passing  beneath  the  clavicle  are  rare,  considering  the 
frequency  with  which  the  clavicle  is  fractured.  If  the  brachial 
plexus  or  axillary  artery  is  injured  symptoms  of  paralysis  or  nerve 
irritation  or  disturbance  in  the  circulation  of  the  upper  extremity 
will  develop. 

Crepitus  is  a  symptom  which  can  almost  always  be  elicited  in 


22  FRACTURES   AND   DISLOCATIONS 

fractures  of  the  clavicle,  except  in  the  incomplete  form  occurring 
in  children. 

Diagnosis. — There  is,  as  a  rule,  little  difficulty  in  recognizing 
fracture  of  the  clavicle  if  the  region  of  the  shoulder  is  carefully 
examined.  The  diagnosis  is  based  on  the  symptoms  just  given. 
Incomplete  fractures  in  children,  and  fractures  of  the  outer  end 
of  the  bone  are  most  likely  to  be  overlooked.  In  establishing  a 
diagnosis  of  fracture  of  the  clavicle  it  is  not  sufficient  to  note  the 
presence  of  a  break  in  a  given  region,  but  the  entire  shoulder  should 
be  examined  to  exclude  associated  lesions.  The  clavicle  should  be 
palpated  from  end  to  end;  occasionally  the  fracture  is  multiple. 
The  spine  of  the  scapula  and  the  acromion  should  be  palpated  and 
the  condition  and  position  of  the  upper  end  of  the  humerus  should 
be  determined.  The  circulation  of  the  forearm  should  be  exam- 
ined and  the  reflexes  noted. 

Treatment. — Reduction  of  the  deformity  in  fractures  of  the 
clavicle  is  usually  a  simple  matter,  being  accomplished  by  pulling 
the  shoulder  outward,  upward  and  backward.  The  deformity 
recurs,  however,  as  soon  as  the  parts  are  released.  Correction  of 
the  displacement,  therefore,  is  useless  prior  to  the  application  of 
retentive  dressings. 

Innumerable  dressings  have  been  devised  for  maintaining  the 
fragments  in  reduction,  but  only  those  which  have  proven  most 
satisfactory  will  be  considered. 

The  modified  Sayre  adhesive  plaster  dressing  will  be  found  most 
satisfactory  in  the  largest  number  of  cases  and  is  applied  with 
three  strips  of  adhesive  plaster,  each  about  four  inches  wide  and 
long  enough  to  encircle  the  trunk  one  and  a  half  times.  Zinc-oxide 
plaster  should  be  used  as  it  is  less  irritating.  Before  the  adhesive 
is  applied  the  axilla  should  be  cleansed,  and  the  arm  and  chest 
sponged  with  alcohol  and  thoroughly  dried.  A  folded  towel  should 
be  placed  in  the  axilla  or  a  few  layers  of  gauze  secured  in  position 
to  prevent  the  arm  from  coming  in  contact  with  the  chest.  If  the 
upper  extremity  is  immobilized  and  skin  is  allowed  to  come  in 
contact  with  skin,  cutaneous  irritation  is  almost  sure  to  follow  and 
may  be  severe.  A  light  folded  towel  or  folded  gauze  should  also 
be  placed  about  the  middle  of  the  arm  before  the  first  strip  of 
adhesive  is  applied. 

The  first  strip  of  adhesive  encircles  the  arm  (the  loop  being 
secured  with  a  safety  pin)   half  way  between  the  shoulder  and 


PRACTtTRER    OV    Tfll']    CI.AVKJLE 


23 


elbow;  the  strip  is  then  continued  under  tension,  across  the  back, 
under  the  opposite  arm  and  on  to  the  chest  anteriorly.  This  strip 
of  adhesive,  when  in  place,  should  pull  the  arm  well  backward. 
The  portion  of  the  dressing  encircling  the  arm  should  be  equi- 
distant from  the  shoulder  and  elbow;  neither  above  nor  below  this 
point.  The  second  strip  begins  behind  the  shoulder,  extends  down 
the  back  of  the  arm,  under  the  elbow,  along  the  dorsal  surface  of 
the  forearm  and  hand,  and  over  the  opposite  shoulder.  As  this 
strip  passes  under  the  elbow  the  adhesive  should  be  split  and  a 
generous  padding  of  cotton  placed  in  position  to  prevent  irrita- 


Fig.    29. — Fracture    of    the    right    clavicle    with    the   usual    symptoms.      The    following 
figures  show  the  application  of  a  modified  Sayre's  dressing  to  this  case. 

tion  at  the  point  of  the  elbow.  As  the  end  of  the  strip  is  being 
attached  to  the  opposite  shoulder  the  hand  should  be  raised  on  the 
chest  and  the  elbow  pulled  forward.  This  second  strip  pulls  the 
elbow  forward  (thus  displacing  the  shoulder  backward  with  the 
middle  of  the  arm  fixed  by  the  first  strip )  and  raises  the  entire  arm. 
When  these  two  straps  are  in  position  the  shoulder  is  pulled 
upward,  backward  and  outward,  thus  meeting  the  requirements  for 
reduction  of  the  displaced  fragments.  A  third  strip  of  adhesive 
plaster  is  then  passed  horizontally  around  the  chest  and  arm  to 
fix  the  arm  to  the  side.  Instead  of  this  strip  a  body-swathe  may 
be  used  to  steady  the  member.  This  dressing,  when  properly 
applied,  immobilizes  the  shoulder  most  satisfactorily.  The  author 
has  found,  however,  that  the  patient  usually  complains  of  the 
confinement  of  the  hand  which  often  shows  considerable  irritation 


24 


FRACTURES   AND   DISLOCATIONS 


Fig.    31. 


Fig.    32. 


Fig.   33. 


Author's  modification  of  a  Sayre's  dressing  applied  to  the  fractured  clavicle  shown 
in  Fig.  29.  In  this  dressing  the  hand  is  not  included,  which  is  a  great  comfort  to  the 
patient  and  does  not  render  the  dressing  less  effective.  Sayre's  dressing  will  meet  the 
indications  better  in  the  greatest  number  of  cases.  When  employed  in  the  treatment  of 
children,  special  care  should  be  taken  in  watching  for  signs  of  irritation  to  the  delicate 
skin.  (See  Figs.  37  and  38. — The  Taylor  brace,  which  is  of  great  advantage  in  the 
treatment  of  children.) 

Fig.  30. — First  strap  of  adhesive  encircles  the  arm  and  then  the  body,  pulling  the 
arm  backward. 

Fig.  31. — Second  strap  of  adhesive  passing  down  the  posterior  aspect  of  the  arm, 
under  the  elbow  and  over  the  opposite  shoulder. 

Fig.  32. — Third  strap  of  adhesive  which  passes  down  the  outer  side  of  the  arm, 
under  the  elbow  and  under  the  hand  to  the  opposite  shoulder. 

Fig.  33. — Another  view  of  the  dressing  showing  the  attachment  of  the  straps  po8 
teriorly. 


FRACTURES   OP    THE    CLAVICLE 


25 


where  it  comes  in  contact  with  the  adhesive.  To  obviate  this  the 
author  has  been  in  the  habit  of  dividing  the  second  strip  into  two 
narrow  strips  applied  as  shown  in  Figs.  32  and  33.  The  first 
strip  passes  down  the  posterior  aspect  of  the  arm,  under  the  elbow, 
and  then  diagonally  across  the  forearm  so  that  it  passes  above  the 
hand  and  over  the  opposite  shoulder.  The  second  strip  passes 
down  the  outer  side  of  the  arm,  under  the  elbow  on  its  outer  aspect, 
and  then  diagonally  across  the  forearm  in  the  opposite  direction 
so  that  it  passes  below  the  hand  and  over  the  opposite  shoulder. 
The  hand  is  thus  left  exposed  and  free  from  irritation,  and  the 
patient  may  move  it  at  will,  thus  relieving  the  discomfort  of  the 
cramped  position  without  in  any  way  disturbing  the  fixation.  (See 
Figs.  29  to  33.)  In  some  instances,  especially  when  the  fracture 
is  in  the  inner  half  of  the  bone,  additional  direct  pressure  may  be 


Fig.    34. — Mohr's    figure-of-eight. 


Fig.   35. — Shows   the   turns   used   in   Vel 
peau's  bandage. 


necessary  to  prevent  upward  displacement  of  the  inner  fragment. 
This  is  accomplished  by  means  of  pads  of  gauze  or  cotton  held  in 
position  by  strips  of  adhesive. 

When  adhesive  plaster  is  not  available  Mohr's  figure-of-eight, 
Velpeau's  bandage  or  a  posterior  figure-of-eight  with  the  turns 
passing  behind  the  shoulders  will  serve  the  purpose  as  an  emergency 
dressing.  These  dressings,  however,  are  all  too  insecure  to  be 
relied  upon  in  permanent  fixation  of  the  clavicle. 

The  recumbent  position  will  almost  invariably  maintain  the  frag- 
ments in  good  position  when  all  forms  of  ambulatory  treatment 
prove  inefficient.  The  patient  should  be  placed  on  a  firm  narrow 
bed,  the  arm  secured  to  the  side  by  means  of  a  swathe,  and  a  small 
firm  pillow  placed  between  the  seapulge  and  fixed  in  position  on 


26  PRACTITRES    AND    DISLOCATIONS 

the  back  l)y  iiu-ans  oL"  strips  of  adhesive.  ^lultiple  fracture  of  tlie 
clavicle  or  simultaneous  fracture  of  botli  clavicles  can  ])e  success- 
fully treated  by  this  method.      (See  Vi^.  'A6.) 

The  test  of  any  dressing  is  the  position  occupii-d  by  tlie  fragments 
and  the  absence  of  undue  constriction  of  the  arm  and  forearm.  No 
matter  wliat  method  is  employed  either  the  presence  of  deformity 
or  strangulation  of  the  upper  extremity  is  a  condition  which  calls 
for  correction  and  indicates  the  inefficiency  of  the  dressing. 

In  adults,  es})eeially  large  persons,  considerable  strength  is 
necessary  in  the  dressing  to  maintain  the  proper  position  of  the 


Fig.  36. — 111  ililVhiih  iM.srs  nTiniilrriii  1  i-i.;itinciii  Will  -i\r  l;(iocI  results  when  otlier 
methods  would  tail.  This  ijliolot;iai)li  was  taken  aljoul  live  yeais  atter  fracture  of  both 
clavicles  (one  clavicle  in  two  places)  and  fractuve  of  the  first  and  second  ribs  on  both 
sides.  Recumbent  treatment  was  employed.  At  the  time  this  photograph  was  taken  it 
was  impossible  to  determine  by  palpation  the  former  positions  of  the  fractures  in  the 
clavicles. 

upper  extremity,  and  accordingly  the  points  of  greatest  pressure 
(the  middle  of  the  arm  and  the  point  of  the  elbow  in  Sayre's 
dressing)    should  be  particularly  well  padded. 

Taylor's  brace  (see  Fig.  37)  is  especially  well  adapted  to  frac- 
tures of  the  clavicle  in  children,  and  allows  freedom  of  motion  of 
both  arms.  Sayre's  dressing,  however,  will  answer  the  purpose 
very  well,  though  the  delicate  skin  of  a  child  must  be  closely  watched 
for  irritation  when  adhesive  plaster  is  employed. 

Operative  Treatment. — Nearly  all  cases  of  fractured  clavicle  can 
be  successfully  treated  either  by  Sayre's  dressing  or  the  recumbent 
method   and  hence  operative   intervention   is  rarely  indicated   in 


FRACTURES   OF    THE    CLAVICLE 


27 


recent  cases.  When,  however,  operation  is  demanded  a  single  loop 
of  suture  material  will  usually  accomplish  all  that  is  required  to 
hold  the  fragments  in  position;  the  Lane  plate  is  almost  never 
needed.  The  incision  is  best  made  a  little  below  and  parallel  to  the 
bone,  rather  than  directly  on  it.  If  the  incision  is  a  little  below 
the  clavicle  a  short  flap  may  be  made,  and  the  danger  of  infecting 
the  wound  from  the  cut  skin  edges  will  be  lessened. 

Most  surgeons  prefer  absorbable  suture  material  (such  as  kanga- 
roo tendon)  to  wire,  in  securing  the  ends  of  the  fragments.  In 
operating  on  the  inner  end  of  the  bone  the  surgeon  should  have  in 


Figs.    37   and   38. — The  C.   F.   Taylor  brace  which   is   particularly   satisfactory   in   the 
treatment  of  fractures  of  the  clavicle  in  children. 

mind  the  relations  of  the  important  structures  passing  between  the 
clavicle  and  the  first  rib.  The  subclavian  vein  lies  directly  behind, 
and  in  contact  with,  the  clavicle  and  subclavius  muscle,  and  just 
external  to  and  behind  the  rhomboid  ligament.  A  little  external 
to  the  vein  and  separated  from  it  by  the  scalenius  anticus  is  the 
subclavian  artery,  which  is  also  in  relation  with  the  clavicle  and 
subclavius  muscle.  If  the  surgeon  does  not  exercise  great  care 
either  of  these  vessels  may  be  injured,  thus  giving  rise  to  serious 
and  troublesome  hemorrhage.  External  to  the  artery  is  the  brachial 
plexus  descending  from  the  neck  into  the  axilla.  Fortunately 
however  fracture  of  the  clavicle  in  the  region  of  these  structures  is 
rare. 

Operation  is  sometimes  demanded  in  old  cases  because  of  injury 


28  FRACTURES   AND   DISLOCATIONS 

to  the  brachial  plexus  with  resultant  paralyses.  These  injuries  are 
usually  due  to  pressure  alone  (without  laceration  of  the  nerves)  and 
if  the  condition  is  not  too  old  removal  of  pressure,  by  dividing  the 
bone  and  raising  the  depressed  fragment,  will  be  all  that  is  required. 
Following  operation  it  will,  as  a  rule,  be  wise  to  fix  the  parts  with 
a  Sayre's  dressing  to  relieve  the  internal  fixation  of  as  much 
strain  as  possible. 

After-Treatment. — Sayre's  dressing  is  the  most  secure  known, 
yet  it  requires  watching  from  day  to  day  to  correct  slipping  and  to 
take  up  the  slack  as  it  develops.  The  fact  that  reduction  is  perfect 
and  immobilization  is  secure  after  the  dressing  is  in  place  should 
not  lead  the  surgeon  to  assume  that  the  same  conditions  will  prevail 
a  week  later. 

]\Iost  text-books  advise  the  removal  of  the  dressing  at  the  end  of 
a  few  days  to  inspect  the  skin  for  evidences  of  irritation  and  to  see 
that  reduction  is  maintained.  This  will  seldom  be  needed  if  the 
dressing  has  been  properly  applied  in  the  first  place.  Additional 
strips  of  adhesive  following  the  course  of  the  "second  strip,"  as 
described  in  the  application  of  Sayre's  dressing,  may  be  used  as 
needed  to  raise  the  elbow  and  correct  the  downward  slipping.  The 
case  should  be  carefully  watched  for  signs  of  cutaneous  irritation, 
strangulation  of  the  circulation  of  the  arm  and  for  the  partial  recur- 
rence of  deformity. 

In  the  uncomplicated  case  in  a  child,  union  may  be  expected  at 
the  end  of  two  and  a  half  or  three  weeks,  though  the  callus  at  this 
time  is  in  no  condition  to  withstand  any  considerable  strain.  In 
adults  a  month  or  a  little  more  is  necessary  for  the  fragments  to 
unite.  The  dressings  may  be  removed  at  the  end  of  three  to  five 
weeks,  according  to  the  age  of  the  patient,  and  the  arm  carried  in  a 
sling  for  another  week  or  ten  days.  During  the  after-treatment  the 
dressing  should  be  changed  every  ten  days  and  the  parts  carefully 
inspected  and  cleansed.  In  removing  the  dressing  the  patient  is 
best  placed  in  the  recumbent  position  so  that  the  clavicle  will  not 
be  subjected  to  strain  during  the  change  from  the  old  dressing  to 
the  new.  Care  should  be  exercised  not  to  pull  the  shoulder  forward 
as  the  old  dressing  is  being  removed  and  the  new  one  applied. 
With  the  upper  extremity  released  it  is  well  to  fully  extend  the 
elbow  and  gently  abduct  the  shoulder  without  disturbing  the 
clavicle.  This  will  aid  in  keeping  these  joints  free,  and  will  be 
followed  by  more  rapid  resumption  of  function  when  the  dressings 


FRACTURES   OP    THE    CLAVICLE  29 

are  permanently  removed.  If  the  dressings  are  replaced  in  the 
sitting  position  the  surgeon  should  have  an  assistant  to  confine 
his  entire  attention  to  holding  the  shoulder  upward,  backward  and 
outward  while  the  dressings  are  being  changed.  Massage  and 
passive  motion  should  be  instituted  as  soon  as  the  dressings  are 
permanently  removed,  but  care  should  be  exercised  not  to  submit 
the  clavicle  to  strain  before  the  callus  is  well  formed.  These 
measures  are  of  the  greatest  value  in  keeping  up  the  tone  of  the 
muscles  and  in  maintaining  the  integrity  of  the  articular  surfaces 
following  operations  on  the  nerves,  pending  the  regeneration  of 
these  structures. 

Prognosis. — In  the  usual  fracture  of  the  clavicle  complete  resto- 
ration of  function  and  strength  should  follow  proper  treatment. 
If  the  fragments  have  been  allowed  to  unite  in  deformity  there 
will  be  some  loss  of  function,  varying  with  the  degree  of  deformity, 
and  if  the  brachial  plexus  is  impinged  upon  there  may  be  a  more 
or  less  complete  paralysis  of  the  upper  extremity.  If  the  disturb- 
ance in  function  is  due  simply  to  mechanical  causes  surprising 
improvement  may  take  place  as  the  years  go  by.  The  complication 
most  often  rendering  the  prognosis  bad  is  injury  to  the  brachial 
plexus.  "When  this  structure  is  damaged  the  outlook  will  depend 
on  the  nature  arid  extent  of  the  injury,  and  the  length  of  time  the 
paralysis  has  been  established.  "With  paralysis  existing  a  year  or 
two  there  is  little  chance  of  improving  the  condition  by  operation, 
but  even  under  these  circumstances  there  is  everything  to  gain  and 
nothing  to  lose,  and  it  is  advisable,  therefore,  to  expose  the  plexus 
and  do  what  can  be  done  by  relieving  pressure  and  suturing  divided 
nerve  ends.  In  recent  cases  the  prognosis  is  not  bad  if  operated 
early,  although  the  process  of  regeneration  may  extend  over  months 
or  even  a  year. 

In  the  uncomplicated  case  of  fracture  of  the  clavicle  the  prog- 
nosis is  good  whether  in  child  or  adult,  provided  proper  treatment 
is  carried  out. 


CHAPTER  IV. 

DISLOCATIONS  OF  THE  OUTER  END  OF  THE  CLAVICLE. 

Surgical  Anatomy. — The  acromio-elavicular  articulation  is  of 
the  arthrodial  type  and  is  composed  of  two  small,  nearly  flat,  oval 
facets,  one  on  the  acromion  and  the  other  on  the  outer  end  of  the 
clavicle.  The  plane  of  this  articulation  is  not  at  right  angles  with 
the  long  axis  of  the  clavicle  but  is  so  placed  that  the  clavicular 
facet  looks  downward,  outward  and  backM^ard.  The  result  then 
(when  the  acromion  is  forced  inward  toward  the  base  of  the  neck) 
is  that  the  clavicle  will  tend  to  slip  upward  onto  the  top  of  the 
acromion.  Violence  of  this  type,  however,  is  more  likely  to  pro- 
duce fracture  of  the  clavicle  than  dislocation  of  either  end.  An 
inter-articular  fibro-cartilage  is  sometimes  present  between  the  two 
articular  facets.  The  joint  depends  entirely  on  the  ligaments  sur- 
rounding it  and  those  passing  between  the  coracoid  and  the  clavicle. 
The  coraco-clavicular  ligaments  play  an  important  part  in  reinforc- 
ing this  joint  and  are  iisually  torn  when  the  displacement  is 
pronounced. 

Nearly  all  the  dislocations  of  the  acromio-elavicular  joint  are  of 
the  upward  type.  About  a  dozen  cases  of  downward  luxation  have 
been  reported.  Another  form  of  dislocation  is  one  in  which  the 
clavicle  is  displaced  downward  and  forward  beneath  the  coracoid 
process,  but  the  few  cases  reported  are  questionable  and  the  type  is 
doubtful. 

The  upward  luxation  is  described  as  complete  or  incomplete, 
according  to  whether  or  not  the  articular  facets  clear  each  other. 
The  acromio-elavicular  ligaments  are  more  or  less  completely  torn, 
and  the  coraco-clavicular  ligaments  may  be  partially  or  completely 
ruptured,  depending  on  the  extent  of  the  displacement  and  the 
degree  of  violence. 

Direct  violence  is  usually  responsible  for  luxations  of  the  acromio- 
clavicular joint,  though  muscular  action  is  known  to  have  produced 
the  condition.  A  downward  blow  on  the  acromion  may  displace 
this  process  downward  while  the  clavicle  is  prevented,  to  some 

30 


DISLOCATIONS   OF   OUTER  END   OF    CLAVICLE 


31 


Fig.    39. — Dislocation    of    the    outer    end    of    the    clavicle    and    separation    of    acromial 
epiphysis.      The   lower   arrow  points   to  the   displaced  epiphysis. 


32  FRACTURES   AND   DISLOCATIONS 

extent,  from  accompanying  it  by  the  action  of  the  trapezius.  The 
same  type  of  violence  which  produces  fracture  of  the  clavicle  may 
in  rare  instances  be  responsible  for  luxations  of  the  outer  end. 

Symptoms. — Dislocations  of  the  clavicle  vary  with  the  direction 
of  the  displacement  and  the  extent  of  ligamentary  rupture.  There 
is  always  more  or  less  pain  in  the  region  of  the  acromio-clavicular 
articulation  which  is  increased  by  both  active  and  passive  motion 
of  the  sliouldcr.     Disabilitv  varies  greatly  in  different  cases.     Cora- 


Fig.   40.- — Dislocation   of   the  outer   end   of   tin    clavii-le   a   few   minute.s   following   the 
accident.      Note  the  prominence  indicated  by  the   arrow. 

plete  loss  of  function  may  be  present  in  some  cases  while  in  others 
the  patient  may  be  able  to  use  the  shoulder,  though  the  action  of 
the  part  is  more  or  less  restricted  by  pain.  It  is  probable  that  this 
variation  in  disability  depends  largely  on  the  extent  of  laceration 
in  the  coraco-clavicular  ligaments.  The  nature  of  the  deformity 
varies  with  the  type  of  luxation. 

In  the  common  upward  variety  a  distinct  prominence  is  noted  at 
the  outer  end  of  the  clavicle.  In  the  incomplete  form  the  promi- 
nence of  the  displaced  outer  end  is  not  great,  being  as  a  rule  less 
than  the  thickness  of  the  bone.  In  the  complete  form  the  outer  end 
of  the  bone  stands  out  prominently  and  may  be  moved  about  on 
palpation.     By  pressing  on  the  outer  end  of  the  clavicle  and  raising 


DISLOCATIONS   OP    OUTER   END   OP    CLAVICLE 


33 


the  shoulder,  the  prominence  may  be  made  to  disappear  as  the  luxa- 
tion is  reduced.  Recurrence  of  deformity  is  prompt  with  release 
of  the  shoulder.  A  rotary  displacement  of  the  scapula  is  noted 
in  some  instances;  the  tip  of  the  body  being  more  prominent  than 
normal,  while  the  spine  and  acromion  are  depressed.  If  the 
clavicle  is  grasped  in  its  middle  third,  where  it  is  free  from  heavy 
muscular  attachments,  and  manipulated,  pain  will  be  produced  at 
the  outer  end. 


Fig.    41 


Figs.  41  and  42. — Dislocation  of  the  acromial  end  of  the  clavicle  shortly  following 
accident.  Note  the  forward  and  downward  displacement  of  the  shoulder  and  the  ab- 
normal prominence  of  the  outer  end  of  the  clavicle  which  slightly  overlaps  the  acromion. 
Further  displacement  is  prevented  by  the  coraco-clavicular  ligaments  which  remain  intact. 

In  the  downward  type  of  luxation  the  outer  end  of  the  bone  lies 
below  the  acromion  and  is  displaced  backward.  The  middle  third 
of  the  shaft  is  less  prominent  than  normal,  the  trunk  is  inclined  to 
the  injured  side  and  the  shoulder  is  lowered.  The  downward  dis- 
placement of  the  outer  end  causes  the  sternal  extremity  to  become 
unduly  prominent.  The  entire  inner  border  of  the  acromion  is 
palpable  and  the  articular  facet  may  be  felt.  It  will  usually  be 
possible  to  feel  the  clavicle  at  the  point  .where  it  passes  under  the 
acromion. 

In  the  suhcoracoid  form  the  clavicle  is  said  to  be  lodged  under 
the  coracoid  process.  The  outer  end  of  the  bone  lies  in  the  axilla 
and  there  is  great  ecchymosis  in  the  region  of  the  coracoid. 

Diagnosis. — In  the  usual  type  of  acromio-clavicular  luxation  the 


34 


FRACTURES   AND    DISLOCATIONS 


diagnosis  may  be  tentatively  made  by  inspection  alone.  The  nature 
and  position  of  the  prominence  is  characteristic.  Manipulation  of 
the  clavicle  or  shoulder  causes  motion  at  the  acromio-clavicular 
joint.  The  region  of  the  prominence  should  be  carefully  i)alpated 
to  exclude  fracture  of  the  outer  end  of  the  clavicle,  and  fracture  of 
the  acromion.  Eitlier  of  these  conditions  is  productive  of  crepitus. 
The  ligaments  sometimes  avulse  a  small  portion  of  either  clavicle 
or  acromion  in  lieu  of  rupture  of  the  ligament  itself,  ami  when  this 


Fig.    43. —  Downward    (lisslocatinn    cf 
of   the    clavicle    is    cau2:lit    under    the    acromion 
the  one  of  least   discomfort. 


i-i-    .■,1.1    (if    till'    clavicle.      The    outer    end 
nd    tlic    [latipnt    assumes    this    attitude    as 


occurs  the  surgeon  may  be  able  to  elicit  crepitus  and  mistake  the 
condition  for  fracture.  Careful  palpation,  however,  will  determine 
the  false  motion  in  the  joint  itself  and  not  to  the  outer  or  inner 
side  of  it.  The  displaced  axis  of  the  clavicle  and  the  relatively 
raised  acromion  should  suggest  the  condition  in  the  rare  downward 
type. 

Treatment. — In  the  common  type  of  luxation  reduction  is,  as  a 
rule,  easily  eft'ected  by  upward,  outward  and  backward  traction  on 
the  shoulder.  Recurrence  of  deformity,  however,  is  the  rule  and 
retentive  dressing  should  be  at  hand  to  maintain  the  outer  end 
of  the  clavicle  in  position  as  soon  as  reduction  is  accomplished. 
Stimson's  adhesive  plaster  dressing  is  quite  satisfactory  in  prevent- 


DISLOCATIONS   OF    OUTER   END   OP    CLAriCI.E 


85 


ing  redisplacement.  The  axilla  is  first  cleansed,  sponged  with 
alcohol,  and  dried  and  a  folded  towel  is  placed  between  the  arm  and 
the  chest  to  prevent  skin  coming  in  contact  with  skin  during  the 
subsequent  immobilization.  The  arm  is  then  placed  at  the  side 
and  the  elbow  semiflexed.  A  strip  of  adhesive  four  feet  long  and 
three  or  four  inches  wide  is  then  placed  under  the  elbow.  One  end 
is  carried  up  the  anterior  aspect  of  the  arm  and  over  the  shoulder 
at  the  site  of  luxation.  The  posterior  end  of  the  plaster  is  carried 
up  the  posterior  aspect  of  the  arm  in  a  similar  manner  and  carried 
forward  over  the  shoulder.     As  the  ends  of  this  dressing  are  being 


Fig.   45. 


Fig.   44. — Dressing   to    maintain    reduction    in   luxation   of    the   outer   end   of   clavicle. 
Fig.    45. — .S.ame  principle  carried  out  witli  adhesive  jjlaster  instead  of  bandage.      Note 
the   pad   over   outer   end   of    clavicle. 

brought  into  position  the  shoulder  should  be  raised  upward,  back- 
ward and  outward,  and  pressure  should  be  made  on  the  outer  end 
of  the  clavicle.  When  the  plaster  is  properly  placed  it  pulls 
upward  on  the  semiflexed  elbow  and  exerts  downward  pressure  on 
the  outer  third  of  the  clavicle.  The  arm  is  then  secured  to  the  side 
by  means  of  a  body  swathe  and  the  forearm  carried  in  a  sling. 

In  the  downward  type  of  luxation  reduction  is  accomplished  by 
outward  traction  on  the  shoulder  and  direct  manipulation  of  the 
clavicle  by  grasping  it  in  its  middle  third.  Recurrence  of  deform- 
ity does  not,  as  a  rule,  occur  following  reduction,  and  accordingly^ 


36  .   FRACTURES  AND   DISLOCATIONS 

no  retentive  apparatus  other  than  a  sling  and  body  swathe  will  be 
needed. 

Operative  Treatment. — Open  treatment  is  seldom  indicated 
since  reduction  can,  as  a  rule,  be  niaiiitained  by  the  dressings  just 
described.  In  exceptional  instances  suture  of  the  outer  end  of  the 
clavicle  to  the  acromion  may  be  needed  to  prevent  recurrence  of 
deformity.  Both  wire  and  absorbable  suture  material  have  been 
successfully  employed.  It  may  be  possible  in  some  eases  to  suture 
the  ligaments  about  the  end  of  the  bone  in  such  a  manner  as  to 
obviate  the  necessity  of  drilling  into  the  bone.  In  the  downward 
variety  of  luxation  operation  may  be  called  for  to  disengage  the 
outer  end  of  the  clavicle. 

After-Treatment. — The  clavicle  should  be  watched  for  recurrence 
of  deformity  especially  following  the  upward  type  of  luxation.  A 
certain  amount  of  slipping  will  take  place  in  the  dressings  and 
should  be  corrected  to  keep  the  end  of  the  bone  in  position.  Irrita- 
tion may  develop  at  the  site  of  pressure  and  require  attention. 
Three  to  four  weeks  should  be  allowed  for  the  ligaments  to  heal. 

Prognosis. — The  outlook  in  the  ordinary  case  of  luxation  of  the 
outer  end  of  the  clavicle  is  good  as  far  as  restoration  of  function  is 
concerned.  The  prominence  of  the  articulation  may  be  a  little 
greater  than  normal  when  recovery  is  complete,  and  in  some  cases 
a  slight  amount  of  displacement  maj'  persist,  but  these  conditions 
are  not  incompatible  with  free  use  of  the  part  and  a  strong  joint. 
Downward  luxations  may  be  attended  by  injury  to  the  brachial 
plexus  since  this  displacement  decreases  the  space  between  the 
clavicle  and  the  first  rib,  and  the  prognosis  will  depend  on  the 
severity  of  the  plexus  involvement.  Old  unreduced  luxations  often 
show  a  remarkable  restoration  of  function  and  the  formation  of  a 
new  joint. 


CHAPTER  Y. 

FRACTURES  OF  THE  SCAPULA. 

Surgical  Anatomy. — The  freedom  of  motion  in  this  bone  and  the 
fact  that  it  is  almost  entirely  surrounded  by  heavy  muscles,  account 
for  the  rarity  with  which  it  is  fractured.  Some  portions  of  the 
scapula  (spine  and  acromion  process)  are  subcutaneous  and  accord- 
ingly more  often  injured.  The  acromial  epiphysis  usually  joins 
the  remainder  of  the  bone  between  the  eighteenth  and  twenty-fifth 


Figs.   46   and  47. — Ventral   and   dorsal   surfaces   of   the  right   clavicle.      A.,   Acromion 
sss ;   C,  Coracoid  process ;   G.,  Glenoid  cavity. 


process 

years,  although  it  may  remain  ununited  throughout  life.  This 
condition  has  been  mistaken  for  fracture.  The  attachments  of  the 
deltoid  and  trapezius  tend  to  prevent  displacement  when  this 
portion  of  the  bone  is  broken.  The  attachment  of  these  muscles  and 
the  heavy  fibrous  tissue  surrounding  the  acromion  and  spine 
explain  the  difficulty  of  eliciting  crepitus  in  the  presence  of  fracture 
in  this   region.     When,   however,   these   structures   are   lacerated 

37 


38  FRACTrRES   AND    DISLOCATIONS 

sufficiently  to  allow  displacement,  crei)itus,  abiioniial  mohility  and 
deformity  are  recognized  without  ditificulty.  If  the  fracture  is 
internal  to  theacromio-clavicular  articulation  we  have  a  condition 
closely  resembling  dislocation  of  the  outer  end  of  the  clavicle. 

Fracture  of  the  coracoid  is  an  extremely  rare  occurrence.  It  has 
been  broken  as  the  result  of  muscular  action  due  to  the  pull  of  the 
short  head  of  the  biceps,  coraco-brachialis  and  pectoralis  minor. 
Epiphyseal  separation   of  tliis   ])roeess  has   been   known   to  occur 


Fig.    48. — ^View  of  the  same  honi'  fioni  the  axillary   border.      Note  the  relation  of  the 
coracoid  and  acromial  processes  to  the  glenoid  cavity. 

prior  to  the  seventeenth  3^ear,  at  which  time  ossification  makes  it 
continuous  with  the  rest  of  the  bone. 

Fracture  of  the  glenoid  cavity  usually  results  from  violence 
transmitted  through  the  head  of  the  humerus.  It  may  exist  as  a 
complication  of  fracture  or  dislocation  of  the  humeral  head. 
Fracture  of  the  neck  of  the  scapula  may  occur  from  similar  causes. 
The  thinnest  and  best  protected  portion  of  the  bone  is  the  hody. 
Fracture  rarely  occurs  in  this  region,  but  when  it  does  it  is  almost 
invariably  the  result  of  direct  violence.  The  spring  of  the  ribs 
supporting  the  scapula  undoubtedly  enables  it  to  withstand  greater 
violence,  but  when  trauma  is  severe  we  may  have  fracture  of  the 


FRACTURES    OF    TIIR    SCAPULA 


39 


underlying  ribs  as  well  as  of  the  body  of  the  bone.  When  such  is 
the  case,  the  more  superficial  fracture  may  conceal  the  injury  to 
the  ribs.  Fracture  of  the  body  is  usually  transverse  below  the 
spine.     Comminution  is  sometimes  observed  and  in  rare  instances 


Fig.   49. — Fracture   of   the   neck   of   tin- 


the  line  of  fracture  may  cross  the  spine.  The  attachments  of  the 
infraspinatus,  subscapularis,  serratus  magnus,  rhomboid  and  teres 
muscles  are  such  that  pronounced  displacement  rarely  occurs  and 
palpation  is  difficult. 


40  FRACTURES   AND    DISLOCATIONS 

Symptoms. — Loss  of  fuuetiou,  and  pain  (wliieli  is  increased  on 
moliDii)  are  always  present.  Deep  respiration  causes  suffering, 
though  tlic  j-ai)id  sliallow  breathing,  characteristic  of  fractures  of 
tlie  ribs,  is  absent.  The  body  of  the  scapula  may  be  grasped  as 
sliown  in  Fig.  50  when  abnormal  mobility  and  crepitus  are 
elicited,  completing  the  list  of  symptoms. 

Fracture  of  the  acromion  process  produces  localized  pain,  tender- 
ness, and  sometimes  limited  mobility  and  crepitus.  The  symptoms 
vai-y  with  the  position  of  the  fracture  in  relation  to  the  acromio- 
clavicuUir  articulation.  Fracture  of  the  acromion,  external  to  the 
acromio-clavii'ular  joint,  produces  local  pain  and  tenderness. 
Crepitus  and  abnormal  mobility  may  be  present  on  manipulation, 
but  deformity  is  almost  uniformly  absent.  Fracture  of  the 
acromion  entering  the  articulation  gives  rise  to  symptoms 
closely  resembling  fracture  external  to  the  joint,  though  mo- 
tions of  the  shoulder  are  usually  more  painful.  Fracture  of  the 
acromion  internal  to  its  articulation  with  the  clavicle,  is  accom- 
panied by  symptoms  almost  identical  with  dislocation  of  the  outer 
end  of  the  clavicle,  especially  if  the  muscular  and  fibrous  attach- 
ments of  the  process  have  been  torn  sufficiently  to  allow  deformity. 
The  shoulder  drops  downward,  forward  and  inward,  and  undue 
prominence  is  observed  at  the  outer  end  of  the  clavicle.  Palpation 
reveals  the  acromial  fragment  attached  to  the  outer  end  of  the 
collar  bone.  Abnormal  mobility  of  the  displaced  acromial  frag- 
ment is  present,  but  crepitus  is  absent  unless  the  fractured  surfaces 
have  remained  in  contact. 

Fracture  of  the  coracoid  gives  rise  to  localized  pain  and  tender- 
ness just  below  the  junction  of  the  middle  and  outer  thirds  of  the 
clavicle.  Displacement,  if  present,  is  very  slight  owing  to  the  fact 
that  the  rhomboid  and  trapezoid  ligaments  are  seldom  torn.  These 
ligaments  securely  hold  the  fragment  in  position  against  the  actions 
of  the  attached  muscles.  The  tip  of  the  coracoid  may  be  palpated 
if  pressure  is  made  at  the  proper  point  below  the  clavicle.  It  is 
impossible,  however,  to  grasp  the  process  betw'een  the  fingers,  and 
for  this  reason  it  is  difficult  to  elicit  crepitus  and  abnormal  mobility. 

Fracture  of  the  surgical  neck  of  the  scapida  gives  a  picture 
somewhat  resembling  dislocation  of  the  shoulder,  although  the 
deformity  is  not  characteristic  of  any  type  of  shoulder  luxation, 
and  crepitus  can  usually  be  elicited  by  manipulation.  Fracture  of 
the  glenoid  cavity,  especially  a  fragment  from  the  anterior  edge. 


FRACTURES  OF    THE   SCAPULA 


41 


is  a  complication  sometimes  occurring  in  dislocations  of  the 
shoulder,  and  results  in  spontaneous  recurrence  of  deformity  fol- 
lowing reduction.     Crepitus  may,  or  may  not,  be  present. 

Diagnosis. — A  consideration  of  the  symptoms  occurring  in  frac- 
tures of  different  regions  of  the  scapula  should  render  the  diagnosis 
in  most  cases  easy.  Fracture  of  the  acromion  and  body  are  by  far 
the  most  common  injuries  seen  in  this  bone.  Fracture  of  the 
surgical  neck  may,  at  times,  be  extremely  difficult  to  differentiate 
from  dislocations  of  the  shoulder  and  fractures  of  the  upper  end  of 


Fig. 
fracture. 


50. — Method    of    grasping    the    body    of    the    scapula    to    detect    the    presence    of 
The  fingers  of  the  right  hand  are  palpating  the  spine  of  the  scapula. 


the  humerus.  Deep  palpation  of  the  axilla  may  detect  the  glenoid 
cavity  moving  with  the  head  in  its  inward  displacement.  Fractures 
of  the  glenoid  cavity,  surgical  neck  and  coracoid,  may  require  the 
use  of  the  X-ray  before  diagnosis  can  be  established.  The  fre- 
quency with  which  radiography  reveals  unsuspected  conditions  in 
and  about  the  shoulder  demonstrates  the  value  of  the  X-ray  as  a 
routine  measure  in  injuries  of  this  region.  The  difficulty  of 
diagnosis  is  greatly  increased  if  the  case  is  not  seen  for  twenty-four 
or  forty-eight  hours  following  the  accident.  By  this  time  the 
swelling  and  tenderness  have  so  increased  that  less  is  learned 
from  inspection  or  palpation,  and  manipulation  of  the  parts  is 
seriously  objected  to  by  the  patient.     An  anesthetic  is  often  neees- 


42  FRACTURES   AND    DISLOCATIONS 

sary  to  deterniiiio  the  condition,   especially   if  the  X-ray  is  not 
available. 

Treatment. — The  treatment  must,  of  necessity,  vary  with  the 
region  and  function  of  the  portion  of  the  bone  injured.  Fracture 
of  the  body  of  the  bone  calls  for  strapping  of  the  chest  in  such  a 
manner  that  the  scapula  will  be  immobilized.  In  addition  the  arm 
should  be  fixed  to  the  side  of  the  chest  by  a  swathe  or  additional 
strapping.  The  Velpeau  bandage  may  be  used  to  advantage, 
especially  when  reinforced  with  starch  or  plaster  of  Paris.  Oppos- 
ing surfaces  of  skin  should  be  protected  by  the  intei'po-ition  of  some 


Fig.   51. — Oblique    strapping    with    adhesive    plaster    to    immobilize    the    body    of    the 
scapula. 

absorbent  material,  such  as  cotton.  In  fracture  of  the  acromial 
process,  especially  with  displacement,  the  indications  in  treatment 
are  similar  to  those  of  fracture  of  the  clavicle.  A  Sayre's  dressing, 
or  modification,  such  as  shown  on  page  24,  will  answer  the  purpose 
satisfactorily.  Additional  pressure  directly  over  the  fragment  may 
be  had  by  means  of  a  strap  of  adhesive  and  pad  of  gauze  appro- 
priately placed.  In  fracture  of  the  coracoid  process  direct  immo- 
bilization of  the  fragment  is  hardly  possible,  yet  the  arm  should  be 
so  fixed  to  the  side  as  to  prevent  action  of  the  three  muscles  attached 
to  the  process.  The  indications  in  the  treatment  of  fractures  of 
the  surgical  neck  of  the  scapula  are  similar  to  those  of  fracture  of 
the  upper  end  of  the  humerus.  The  axillary  pad  and  plaster  of 
Paris  shoulder  cap  can,  as  a  rule,  be  so  applied  that  the  fragment 
is   held    in   proper    reduction.     (See    Figs.    332    to    140.)     It    is 


FRACTfJRES  OF   THE   SCAPULA  43 

usually  unwise  to  allow  use  of  the  forearm  or  hand  in  fractures  of 
any  portion  of  the  scapula.  In  the  less  severe  conditions  the  arm 
should  at  least  be  carried  in  a  sling,  while  the  remainder  of  the 
upper  extremity  is  securely  immobilized. 

After-Treatment. — Union  will  usually  take  place  within  a  month. 
When  fracture  occurs  in  parts  of  the  scapula  which  are  subject  to 
considerable  strain,  such  as  the  neck  of  the  bone  or  the  acromion, 
internal  to  its  articulation  with  the  clavicle,  immobilization  should 
be  maintained  for  about  two  weeks  longer.  The  dressings  should 
be  carefully  inspected  daily  for  the  first  week  to  avoid  loosening 
and  slipping.  If  irritation  of  the  skin  occurs  it  should  receive 
proper  attention. 

Prognosis. — Fractures  of  the  body  of  the  scapula  seldom  produce 
permanent  impairment  of  function.  Fractures  of  the  surgical 
neck,  and  of  the  acromion  with  displacement,  may  be  followed  by 
some  loss  of  function,  if  not  properly  reduced.  Perfect  function 
is  likely  to  follow  fibrous  union  of  the  coracoid. 


CHAPTER  YI. 

DISLOCATIONS  OF  THE  SHOULDER. 

Surgical  Anatomy. — The  peculiar  construction  of  the  shoulder 
joint,  its  wide  range  of  motion  and  exposed  position,  result  in  its 
being  the  most  common  site  of  dislocation  in  the  body. 

The  articulation  is  typical  of  the  ball  and  socket  joint.  The 
bones  entering  into  its  formation  are  the  head  of  the  humerus  and 
the  glenoid  cavity  of  the  scapula.  The  acromion  and  eoracoid 
processes,  with  the  coraco-acromial  ligament  stretching  between 
them,  are  not  considered  a  part  of  the  joint  proper,  yet  they  play 
an  important  part  in  preventing  upward  displacement  of  the 
humeral  head.  The  wide  range  of  motion  possible  in  this  joint  is 
the  result  of  the  disproportion  in  the  sizes  of  the  articular  surfaces 
of  the  humeral  head  and  glenoid  cavity.  Extreme  mobility 
renders  the  upper  extremity  more  serviceable  in  many  ways,  but 
on  the  other  hand  it  is  evident  that  this  type  of  joint  construction 
is  dependent  almost  entirely  on  ligaments  and  muscles  for  its 
stability.  The  coraco-acromial  and  capsular  are  the  only  ligaments 
of  surgical  importance  in  the  shoulder  joint.  The  coraco-acromial 
ligament  arches  over  the  head  of  the  humerus,  filling  in  the  space 
between  the  two  processes  and  serves  to  prevent  upward  displace- 
ment of  the  humerus.  The  capsular  ligament  entirely  surrounds 
the  articulation,  being  attached  to  the  rim  of  the  glenoid  cavity 
just  beyond  the  glenoid  ligament,  and  externally  to  the  anatomical 
neck  of  the  humerus.  This  ligament  is  much  too  lax  on  all  sides 
to  keep  the  articular  surfaces  in  contact,  but  this  very  laxity  is 
necessary  to  allow  the  freedom  of  motion  which  this  joint  enjoys. 
A  portion  of  the  capsule  becomes  taut  only  when  the  arm  is  carried 
to  the  extreme  limit  of  motion  in  a  given  direction.  (See  Figs. 
52  and  53.)  Some  portions  of  the  capsule  are  more  subject  to 
strain  than  others,  and  accordingly  Ave  find  such  parts  reinforced 
by  muscle  tendons  or  thickenings  in  the  capsule  itself.  These 
thickenings  have  been  given  special  names,  such  as  the  coraco- 
humeral  in  the  upper  part  of  the  joint,  and  the  ligaments  of  Flood 

44 


DISLOCATIONS   OP    THE    SHOULDER 


#■ 


and  Schlemm  anteriorly.  The  transverse  humeral  ligament  serves 
to  confine  the  long  tendon  of  the  biceps  within  the  bici[)itfil  groove, 
and  the  glenoid  ligament  forms  a  margin  around  the  glenoid  cavity, 
increasing  its  depth.  The  ligaments  surrounding  the  joint  prevent 
dislocation  by  limiting  the  range  of  motion,  while  the  muscles,  by 
their  tonicity,  actively  hold  the  articular  surfaces  in  apposition. 
The  deltoid  arising  from  the  clavicle,  acromion  and  spine  of  the 
scapula  keeps  the  humerus  well  up  in  place  against  the  under  sur- 
face of  the  arch  made  by  the  coracoid,  coraco-acromial  ligament 
end  acromion.     Paralysis  of  this  muscle  results  in  a  dropping  of 


Fig.   53. 


Fiss.  52  and  53. — Diagrams  illustrating  the  action  of  the  capsule  in  different  posi- 
tions of  the  joint.  It  is  apparent  that  it  must  be  lax  enough  on  all  sides  to  allow 
motion  of  the  humerus  in  different  directions  and  that  its  function  is  to  limit  motion  and 
not  to  hold  the  humeral  head  firmly  against  the  glenoid  cavity. 

the  humerus  with  separation  of  the  articular  surfaces  in  the 
shoulder  joint.  The  tendon  of  the  long  head  of  the  biceps 
strengthens  the  upper  part  of  the  capsule,  keeps  the  head  of  the 
humerus  in  proper  apposition  with  the  glenoid  during  the  various 
movements  of  the  arm  and  prevents  the  head  from  being  pulled  too 
closely  upward  under  the  acromion.  The  action  of  the  coraco- 
brachialis  is  similar  to  that  of  the  deltoid  in  holding  the  humerus 
up.  The  tendon  of  the  subscapularis  reinforces  the  capsule,  and 
in  the  anterior  dislocations  is  not  infrequently  torn  when  this 
particular  portion  of  the  capsule  is  penetrated  by  the  head.  The 
tendons  of  the  supraspinatus,  infraspinatus  and  teres  minor  rein- 
force the  capsule  and  aid  in  maintaining  the  proper  relations  of 


46  FRACTURES   AND   DISLOCATIONS 

tlie  articular  surfaces.  The  brachial  plexus  and  axillary  artery 
occupy  a  position  internal  to  the  head  as  they  descend  through  the 
axilla,  and  may  be  injured  in  dislocations  o£  the  slioulder.  In  the 
forward  and  downward  types  of  luxation  direct  pressure  may  be 
made  on  these  structures  by  the  humeral  head;  the  pulsating  axil- 
lary artery  may  often  be  palpated  as  it  stretches  across  the  head  in 
subglenoid  luxations.  The  injuries  sustained  by  the  structures 
about  the  joint  depend  on  the  direction  taken  l)y  the  head  as  it 
leaves  the  glenoid  and  the  degree  of  violence  producing  the  luxa- 
tion. The  planes  of  least  resistance  about  the  joint  lie  between  the 
muscles  rather  than  through  them,  though  naturally  the  greater  the 
violence  producing  the  dislocation  the  greater  the  probability  of  a 
muscle  being  penetrated  by  the  head.  The  subscapularis  is  the 
muscle   most   frequently   penetrated   in   this  manner. 

The  capsular  ligament  is  practically  always  torn  at  the  point 
where  the  head  leaves  the  glenoid  fossa  and,  since  the  common  dis- 
placements are  of  the  anterior  variety,  the  rent  Avill  usually  be 
found  in  the  antero-inferior  portion  of  the  capsule.  A  few  cases 
of  anterior  luxation  without  injury  to  the  capsule  have  been 
reported  in  which  the  joint  was  previously  much  relaxed  and  the 
capsule  unusually  roomy.  Injury  to  the  capsule  is  not  infrequently 
accompanied  by  injury  to  the  tendons  which  overlie  and  reenforce  it 
and,  when  the  violence  producing  the  luxation  is  great,  there  may 
be  a  destruction  of  tendon  continuity. 

The  trauma  causing  the  luxation  may  at  the  same  time  produce 
a  fracture  of  the  glenoid  cavity  or  of  the  upper  end  of  the  humerus. 
The  anterior  rim  of  the  glenoid  may  be  broken  off  by  the  head  of 
the  humerus  as  the  articular  surfaces  are  forced  past  each  other. 
The  head  and  tuberosities  may  suffer  a  variety  of  fractures  which 
are  so  diverse  that  two  cases  are  rarely  seen  alike.  The  greater 
tuberosity  is  sometimes  found  parted  from  the  shaft  and  displaced 
in  the  line  of  the  pull  of  the  muscles  attached  to  it.  This  frag- 
ment may  lie  in  the  glenoid  cavity  where  it  offers  obstruction  to 
reduction.  Fractures  of  the  surgical  neck,  with  or  without  dislo- 
cation of  the  shoulder,  are  more  constant  in  type  than  fractures  of 
the  anatomical  neck.  Fracture  of  the  anatomical  neck,  especially 
when  complicated  by  dislocation,  is  sometimes  represented  by  a 
comminuted,  crushed  condition  of  the  upper  end  of  the  humerus, 
in  which  the  lines  of  fracture  are  extremely  variable.  The  cap  of 
bone   represented  by  the   articular  surface   is  usually   less   com- 


DISLOCATIONS   OF    THK    SMOULDER 


47 


minuted  than  either  the  underlying  structure  or  the  tiibfrosities. 

Fracture  of  the  upper  end  of  the  humerus  more  often   occurs 

in  those  cases  of  dislocation  which  have  been  produced  by  direct 


Fig.   54.  Fig.   .5.5. 

Fig.    54. — Normal    shoulder.      CI.,   clavicle;    C,    coracoid   process;    A.,    acromion    proc- 
ess;   G.,   glenoid  cavity;   H.H.,  humeral  head;    H.S.,   humeral   shaft. 
Fig.   55. — Subcoracoid  dislocation. 


Fig.   56.  Fig.    57. 

Fig.   56. — Intracoracoid  or  subclavicular  dislocation.     CL,  clavicle;  C,  coracoid  proc- 
ess; A.,  acromion  process;  6.,  glenoid  cavity;  H.H.,  humeral  head;  H.S.,  humeral  shaft. 
Fig.   57. — Intraclavicular  dislocation  with  moderate  deformity. 

violence,  the  blow  having  been  sustained  on  the  outer  side  of  the 
shoulder  just  below  the  acromion. 


48 


FRACTURES   AND   DISLOCATIONS 


Separation  of  the  lesser  tuberosity  has  been  noted  as  a  compli- 
cation of  dislocation  of  the  shoulder,  though  it  is  much  rarer  than 
fracture  of  the  necks  or  greater  tuberosity. 

The   most   important   structures  which   may  be   injured   by   the 


Fig.   58. 


Fig.    59. 


Fig.   58. — Subglenoid   dislocation.      67..    clavicle;    C,    coracoid   process;    A.,    acromion 
process;   G.,  glenoid  cavity;  E.H.,  humeral  head;   H.S.,  humeral  shaft. 
Fig.   59. — Luxatio  erecta.     A  variation  of  the  subglenoid  type. 


Fig.    60. 


Fig.    61. 


Fig.    60. — -Subacromial   dislocation.      The   les.s   pronounced    of   the   two   posterior   luxa- 
tions.     H.H.,   humeral   head;    H.S.,    humeral   shaft;    A.,   acromion   process;    S.S.,   spine   of 

SC3rPUl&. 

Fig.   61. — Subspinous  dislocation.      An  exaggeration  of  the  subacromial  type. 


DISLOCATIONS   OF    THE   SHOULDER  49 

displaced  head  are  the  brachial  plexus  and  axillary  artery  which 
lie  just  internal  to  it  in  the  axilla.  When  the  artery  is  torn  hemor- 
rhage into  the  axilla  will  follow,  while  simple  pressure  on  the  vessel 
will  only  temporarily  interfere  with  the  pulse  in  the  arm  below. 
Pressure  on  the  brachial  plexus  may  result  in  partial  or  complete 
paralysis  of  the  parts  supplied  by  it.  The  exact  mechanism  of 
injury  to  the  brachial  plexus  is  not  thoroughly  understood ;  some 
waiters  consider  it  a  result  of  direct  pressure  on  the  nerves  by  the 
head  or  neck  of  the  bone,  while  others  are  of  the  opinion  that  the 
stretching  sustained  by  the  plexus  is  the  usual  method  of  injury. 
In  any  case  this  complication  is  fortunately  rare,  and  the  resulting 
paralysis  usually  transient.  There  is  little  doubt  that  the  plexus 
may  be  injured  in  attempts  at  reduction,  especially  when  the  older 
method  of  using  a  fulcrum  in  the  axilla  is  resorted  to.  Permanent 
injury  to  the  artery  is  seldom  seen ;  as  a  rule  we  may  look  for 
nothing  more  than  a  temporary  suspension  of  circulation  below 
the  point  of  pressure,  during  the  time  the  head  is  out.  When  the 
dislocation  is  allowed  to  remain  unreduced  for  a  few  weeks  fibrous 
tissue  is  formed  about  the  head,  which  will  ultimately  make  a  new 
socket,  and  in  many  instances  we  see  remarkable  restoration  of 
function.  The  usefulness  of  the  joint,  however,  can  never  be 
expected  to  approach  the  normal  under  such  circumstances. 

The  head  of  the  humerus  may  pass  from  the  glenoid  in  almost  any 
direction,  and  this  fact  has  given  rise  to  a  variety  of  classifications 
which  in  many  instances  have  but  served  to  confuse  rather  than 
help  us  to  a  clearer  understanding  of  the  subject.  The  simplest 
classification  will  be  used  here : 

1  Subcoracoid 

J  Subclavicular  (or  intracoracoid) 


Downward 
Backward 


/Subglenoid 

^Subglenoid  erect  (Luxatio  erecta) 


[Subacromial 
1  Subspinous 

Upward  (very  rare) 


By  far  the  most  frequent  dislocation  of  the  shoulder  is  forward, 
and  of  the  two  subvarieties  the  subcoracoid  is  much  more  common. 
The  subglenoid  is  next  in  order  of  frequency,  while  the  erect  type 
is  more  uncommon  than  either  of  the  posterior  varieties. 


50  FRACTURES   AND   DISLOCATIONS 

In  the  subcoracoid  type  the  head  lies  below  the  coracoid  process, 
having  escaped  through  the  antero-inferior  portion  of  the  capsule. 
The  line  to  be  drawn  between  this  luxation  and  the  subclavicular 
variety  is  purely  artificial  and  arbitraiy.  If  more  than  three- 
fourths  of  the  transverse  diameter  of  the  humeral  head  lie  internal 
to  tlie  coracoid  the  luxation  is  known  as  subclavicular.  More  or 
less  inward  rotation   of  tlic   Inuncius   is  present.     The  tendon  of 


Fig.    62. — Outlined   X-ray   of   a  low  subcoracoid   dislocation   of   stioulder. 

the  subscapularis  is  not  infrequently  torn,  and  in  rare  instances 
injury  may  be  sustained  by  the  supraspinatus,  infraspinatus  or 
teres  muscles.  Tearing  of  the  coraco-huineral  ligaments  practically 
never  occurs  in  this  type  of  luxation.  The  head  of  the  bone  often 
lies  on  the  anterior  edge  of  the  glenoid  cavity. 

In  the  subclavicular  type  the  head  continues  inward,  clears  the 
coracoid  process  and  rises  to  a  slightly  higher  level.  The  tearing 
of  the  capsular  ligament  is  usually  more  severe  than  in  the  sub- 
coracoid form  and  rupture  of  the  tendons  inserted  into  the  upper 
end  of  the  humerus  is  more  common.     The  coraco-humeral  liga- 


DISLOCATIONS   OF   THE    SHOULDER  51 

ment  is  often  extensively  torn  and  aocordinj^'ly  Ko(;lier's  metliod 
of  reduction  will  fail. 

Subglenoid  luxations. — In  the  typical  subglenoid  dislocation  the 
head  of  the  bone  lies  below  the  glenoid  cavity.  There  is  no  hard 
and  fast  line  to  be  drawn  between  the  subcoracoid  and  subglenoid 
varieties,  since  in  practice  we  find  the  head  may  occupy  a  position 
anywhere  along  the  anterior  rim  of  the  glenoid  cavity. 

In  the  e7'ect  type  of  subglenoid  luxation  (luxatio  erecta)  the  head 
lies  below  the  glenoid  but  the  arm  is  in  a  position  of  extreme 
abduction. 

In  the  subacromial  type  the  head  of  the  bone  lies  behind  the 
glenoid  cavity  just  under  cover  of  the  acromion.  The  rent  is  in 
the  posterior  portion  of  the  capsule.  The  biceps  tendon  may  be 
torn  out  of  its  groove  and  the  bellies  or  tendons  of  the  muscles 
inserted  into  the  greater  tuberosity  (especially  the  infraspinatus) 
may  be  extensively  torn.  Complicating  fracture  of  the  greater 
tuberosity  is  more  common  in  this  type  of  luxation  than  in  the 
subcoracoid  form.  The  tendon  of  the  subscapularis  may  be  torn 
from  its  insertion  into  the  lesser  tuberosity. 

The  subspinous  form  is  an  exaggeration  of  the  subacromial,  in 
which  the  head  continues  in  its  backward  course  till  it  lies  in  the 
infraspinous  fossa  just  below  the  spine  of  the  scapula.  The  vio- 
lence producing  this  form  is  great  and  it  is  usually  only  a  short 
time  following  the  accident  until  the  surrounding  tissues  and  skin 
covering  the  head  are  filled  with  ecchymotic  blood.  Injury  to 
surrounding  muscles  and  ligaments  is  usually  more  extensive  than 
in  the  subacromial  type. 

The  upward  variety  is  only  possible  when  the  acromion  has  been 
fractured,  and  is  so  extremely  rare  that  it  might  better  be  consid- 
ered a  surgical  curiosity. 

There  is  no  hard  and  fast  line  to  be  drawn  between  the  subcora- 
coid and  subglenoid  varieties  since  in  practice  we  find  the  humeral 
head  may  occupy  positions  at  different  levels  anywhere  along  the 
anterior  rim  of  the  glenoid  cavity.  This  fact  is  demonstrated 
by  the  accompanying  photographs  and  Rontgenograms.  In  like 
manner  the  subcoracoid  luxation  merges  into  the  subclavicular 
type. 

Etiology. — This  is  the  most  common  dislocation  in  the  entire 
body.  It  occurs  most  frequently  in  adult  life  and  results  from 
various  types  of  trauma  applied  to  the  shoulder.     The  most  com- 


52 


FRACTURES   AND   DISLOCATIONS 


moil  form  of  luxation  is  usually  produced  by  violence  applied  to 
the  shouldei-  when  the  arm  is  in  extreme  abduction. 

Symptoms.-  limiicdialely  rollowin^u'  tlie  accident  llie  i)atient 
suffers  severe,  acutt',  nauseating  pain  which  is  increased  l)y  motion 
of  the  affected  shouldei'.  Loss  of  function  is  produced  by  the 
inhibitory  effect  of  pain,  by  the  retlex  spasm  of  tlic  muscles  and  by 


Fig.  63. — Recent  subeoracoid  dislocation  of  left  shoulder.  Note  the  tlattened  shoul- 
der as  indicated  by  the  arrow,  tliie  change  in  the  axis  of  the  humerus  and  the  lower- 
ing of  the  axillary  fold.  This  picture  is  quite  typical  of  the  subeoracoid  form  of  luxa- 
tion. It  will  be  noted  that  the  patient  makes  no  attempt  to  support  the  injured  member 
as  is   commonly   done  in  fractures   of   the   clavicle   or   humerus,    especially   the  latter. 


the  mechanical  disturbance  in  the  joint.  If  the  luxation  is  allowed 
to  go  uncorrected  the  first  two  conditions  grow  gradually  less  while 
the  last  named  persists  and  results  in  permanent  disability.  The 
nature  of  the  deformity  will  depend  on  the  type  of  luxation. 

In  the  suhcoracoid  variety  there  is  a  flattening  of  the  shoulder 
which  when  palpated,  as  shown  in  Fig.  65,  allows  the  examining 
fingers  to  pass  inward  under  the  acromion  process.  The  upper 
end  of  the  humerus  is  displaced  inward  and  the  axis  of  the  arm 


DISLOCATIONS   OP    THE    SHOULDER 


53 


Fig.  64. — Simple  subcoracoid  dislocation  of  left  shoulder  presenting  the  usual 
symptoms:  flattening  of  the  shoulder,  change  in  axis  of  arm  and  lowering  of  the 
axillary   fold. 


Fig.  65. — Examining  depression  below  the  shoulder.  Note  how,  with  moderate 
pressure,  the  fingers  sink  in  below  the  acromion.  Photograph  taken  just  after  the 
accident   and   immediately  prior  to  reduction  by   Kocher's   method. 


54 


FRACTrRES    AND    DISLOCATIONS 


is  altered.  This  chanice  in  tlie  axis  of  the  Imraerus  may  be  recog- 
uized  at  a  glance.  The  liunieral  head  rests  beneath  the  tip  of  the 
coracoid  process  and  occupies  a  slightly  lower  position  tlian  normal. 
Lowering  of  the  humerus  as  a  whole  lowers  the  attaclnuent  of  the 
peetoralis  nuijor  and  accordingly  the  anterior  axiHary  fold  will  be 
lower  on  the  injured  side.  An  abnormal  prominence  will  be  noted 
Ix'low  the  coracoid  where  the  head  has  found  its  new  resting 
plat-c.     The  elbow  seldom  lies  in  contact  with  the  side  of  the  chest 


Fig.    66. 


Fig.    67. 


Figs.  66  and  67. — Lateral  and  aniciior  views  of  a  subcoracoid  lu.xation  of  right 
shoulder.  This  shoulder  has  been  dislocated  eight  times,  the  first  luxation  being  about 
ten  years  ago.  The  manner  in  which  the  fibres  of  the  deltoid  pass  in  straight  lines 
from"  tlie  acromion  to  their  insertion  indicates  the  absence  of  the  head  of  the  humerus 
from  the  glenoid  cavity.  Reduction  accomplished  by  Kocher's  method  with  the  patient 
in   the    sitting   position. 

and  any  attempt  at  adduction  will  meet  with  resistance  and  cause 
additional  pain.  Abduction  Avill  bring  out  the  lines  of  the  already 
prominent  acromion,  accentuate  the  flattening  of  the  shoulder  and 
is  not  specially  productive  of  resistance  and  pain.  It  is  difficult 
to  place  the  hand  of  the  injured  side  on  the  opposite  shoulder  and 
when  this  has  been  accomplished  it  will  be  found  impossible  to  keep 
the  el])ow  in  contact  with  the  chest.  This  symptom  is  character- 
istic of  anterior  luxations  and  is  the  result  of  the  head  being  "off 
center."  A  simple  though  unnecessary  test  is  to  place  a  ruler  on 
the  outer  side  of  the  arm;  it  will  be  noted  that  the  ruler  can  be 
placed  in  contact  with  the  acromion  and  external  epicondyle  simul- 


DISLOCATIONS   OF    THE    SIIOHLDKR 


Fig.   68. — Another  view  of   the   same  case  showing  the  position  of  the  humeral  head 
as  indicated  by  palpation.     The  head  lies  between  the  two  fingers  on  the  shoulder. 


Fig.   70. 


Figs.  69  and  70. — ^Another  subcoracoid  dislocation  of  the  shoulder  presenting  the 
usual  symptoms.  In  this  case  the  head  of  the  humerus  occupies  a  slightly  lower  posi- 
tion than  seen  in  the  cases  shown  on  the  preceding  pages.  The  slight  deltoid  angle 
present  is  the  result  of  this  lower  position  of  the  head.  The  change  in  the  humeral  axis, 
flattening  of  the  shoulder,  lowering  of  the  axillary  fold  and  "deltoid  angle"  are  all  more 
pronounced  than  seen  in  the  typical  subcoracoid  luxation.  This  is  due  to  fact  that  the 
head  of  the  bone  is  lower  and  the  dislocation  assumes  slightly  the  characteristics  of  the 
subglenoid  type. 


56 


FRACTURES   AND   DISLOCATIONS 


i   i 


Fi?.  71. — An  anterior  dislocatiou  of  tUu  shoulder  ubout  half-way  between  the  sub- 
coracoid  and  subglenoid  types.  Compare  this  case  with  those  shown  in  Figs.  H3,  64, 
67,    75   and  77. 


Fig.    72.  Fig.   73. 

Figs.  72  and  73. — Anterior  dislocation  of  the  right  shoulder  with  the  head  occu- 
pying a  slightly  lower  position  than  that  seen  in  the  preceding  case  (Fig.  71).  This 
case  might  properly  be  termed  a  high  subglenoid  luxation.  The  empty  glenoid  is  well 
indicated  by  the  straight  lines  of  the  deltoid  muscle  and  the  prominence  of  the  cora- 
coid  process  with  its  attached  muscles.  The  thumb  pressed  into  the  shoulder  lies  di- 
rectly above  the  displaced  head.  Note  how  closely  this  case  resembles  the  typical  sub- 
glenoid luxation   shown  in  Fig.   77. 


disijOCAtions  of  the  shoulder 


57 


taneously,  which  is  impossible  in  the  normal  shoulder.  The  head 
of  the  bone  may  be  palpated  in  its  new  position  in  the  axilla. 
Slight  abduction  of  the  arm  facilitates  this  portion  of  the  exam- 
ination. The  head  may  also  be  palpated  through  the  deltoid  aud 
pectoralis  major  as  shown  in  Fig.  68. 

The  patient's  attitude  is  characteristic.  In  standing  the  body 
is  inclined  slightly  forward  and  toward  the  injured  side.  This 
position  is  assumed  so  the  displaced  humeral  axis  may  be  ])rought 
more  nearly  to  the  vertical.  There  is  very  seldom  any  attempt 
made  to  support  the  injured  member  but  instead  it  hangs  limp  from 


Fig.   74. 


Fig.    75. 


Fig.  74. — Subglenoid  dislocation  of  right  shoulder.  The  head  of  the  humerus  lies 
below  the  palpating  finger.  While  plowing  the  share  struck  a  rock  and  the  handles  of 
the   implement   were   thrown   violently   upward    and   the   right    shoulder   dislocated. 

Fig.  75. — Same  case.  Tlie  head  of  the  humerus  lies  between  the  two  index  fingers. 
The  brachial  plexus  and  pulsating  axillary  artery  can  be  felt  stretched  across  the  head 
by  the  fingers  palliating  in  the  axilla. 


the  shoulder.  In  the  sitting  position  the  arm  is  rested  on  some 
convenient  object  such  as  a  table,  or  the  arm  of  a  chair.  In  the 
typical  subcoracoid  luxation  the  elbow  is  close  to,  but  not  in  contact 
with,  the  side.  When  the  head  occupies  a  lower  position  on  the 
anterior  rim  of  the  glenoid  abduction  of  the  arm  will  be  more  pro- 
nounced. 

In  the  subclavicular  or  intracoracoid  type  the  shoulder  is  flatter 
and  the  prominence  below  the  clavicle,  caused  by  the  head,  is  nearer 
the  median  line.  After  the  head  clears  the  coracoid  in  its  inward 
course  it  rises  to  a  higher  level,  and  thus  the  whole  humerus 
occupies  a  higher  position  than  that  seen  in  the  subcoracoid  type. 


58  FRACTURES   AND    DISLOCATIONS 

Tlie  level  of  the  anterior  axillary  fold  is  variable.  The  deformity 
depends  somewhat  on  the  completeness  of  rupture  of  the  coraco- 
humeral  ligament.  If  this  ligament  is  completely  ruptured  the 
arm  is  usually  closely  applied  to  the  chest  wall.  If  it  is  only 
partially  ruptured  abduction  of  the  arm  may  be  pronounced  even 
to  the  extent  of  being  held  in  a  nearly  horizontal  position.  It  may 
be  possible  to  palpate  the  empty  glenoid  cavity.  The  arm  usually 
shows  more  or  less  shortening  which  is  accentuated  by  abduction. 
When  the  eoraco-humeral  ligament  is  completely  ruptured  the 
head  may  occupy  an  unusually  low  position  beneath  the  clavicle. 


Fig.   76. —  Same   case  after   hixatioii   had   been   reduced.      Arm  bandaged   and   fi.xed   to 
side  by  strip  of  adhesive  encircling  tlie  chest. 

In  the  suhglenoid  variety  the  humeral  head  rests  on  the  long 
head  of  the  triceps  below  the  glenoid  cavity,  though  this  position 
is  occupied  only  in  the  most  pronounced  cases.  All  the  symptoms 
noted  in  the  subcoracoid  type  are  present  in  exaggerated  form  in 
the  subglenoid  variety.  The  arm  is  lengthened,  the  axillary  fold 
much  lowered,  the  axis  of  the  humerus  pronouncedly  altered  and 
abduction  of  the  arm  is  a  prominent  symptom.  The  lowering  of 
the  humerus  is  greater  in  this  form  than  in  any  other  type  of  luxa- 
tion occurring  at  the  shoulder  joint.  The  outer  side  of  the  arm 
forms  an  angle  ("deltoid  angle")  with  the  insertion  of  the  deltoid 
as  the  apex.  This  angle  is  the  result  of  abduction  and  indicates 
the  low  position  of  the  head. 


DISLOCATIONS   OP    THE    SHOULDER 


59 


Fig.  77. — A  typical  subglenoid  dislocation  of  the  left  shoulder.  Flattening  of  the 
shoulder,  lowering  of  the  axillary  fold  and  change  in  the  humeral  axis  are  much  more 
pronounced  than  in  the  subcoracoid  type.  In  the  subcoracoid  type  the  outer  surface  of 
the  arm  is  approximately  a  straight  line  but  in  this  case  it  will  be  noted  that  a  distinct 
angle  is  formed  which  for  convenience  has  been  termed  the  "deltoid  angle."  The  apex 
of  the  angle  is  indicated  by  the  arrow.  The  upper  arm  of  the  angle  extends  to  the 
acromion  while  the  lower  arm  extends  to  the  external  epicondyle.  The  lower  the  posi- 
tion occupied  by  the  luxated  head  the  more  pronounced  will  this  angle  be. 


Fig.    78. — Typical   subglenoid  dislocation  of  left  shoulder. 

Fig.    79. — Attitude  assumed  by  patient  since  it  is  accompanied  by  less  pain  than  any 
other  position.     This  attitude  is  not  especially  uncommon  in  subglenoid  luxations. 


60  FRACTURES   AND   DISLOCATIONS 

Compare  the  clinical  appearance  of  the  cases  shown  in  the  accom- 
panying illustrations.  Fig.  77  shoM's  a  typical  subglenoid  luxa- 
tion. Fig.  72  shows  a  higher  form  wliile  Fig.  .69  .sliows  wliat 
iiiiiilit  be  tcniicd  a  low  siibcoi-acoid. 


Fig.    80. — Subglenoid    luxation.      Attitude   of   least   discomfort   similar    to    one   seen    in 
Fig.    79. 


Fig.    81. — .\noth('r    view   of    pMliciit    sliinvn    in    Kit;.    80. 

In  the   erect   type   of  siihglcnoid  tusatiejn    (luxatio   erecta)    the 
shoulder  is  dislocated  while  the  arm  is  in  extreme  abduction  and  the 


DISLOCATIONS   OF    THE    SHOULDER 


61 


head  comes  to  rest  at  the  lowest  possible  point,  being  in  some  cases 
even  caught  under  the  long  head  of  the  triceps.  The  attitude  is 
characteristic;  the  arm  is  raised  and  the  hand  usually  rests  on  the 


Fig.  82. — Luxatio  erecta.  Patient  was  liit  liy  a  train  and  sustained  numerous  in- 
juries, among  them  the  one  shown  here.  Extension  in  the  altered  axis  of  the  arm  and 
direct  pressure  on  the  head  accomplished  reduction  without  difficulty.  Two  days  later 
the  patient  died  as  a  result  of  associated  injuries  and  immediately  following  death  the 
dislocation  was  reproduced,  the  upper  extremity  placed  in  the  same  position  as  when 
first  seen  and  the  photograph  taken.  It  was  not  feasible  to  take  a  picture  when  the 
patient  was  first  seen  but  the  position  and  appearance  of  the  extremity  as  shown  here 
are  the  same  as   existed  immediately  following  the  accident. 


Pig.    83. — Another   view   of   patient   shown   in   Fig.    82. 


top  of  the  head.  The  patient  is  unable  to  adduct  the  arm  and  the 
head  may  be  seen  as  well  as  felt  in  the  axilla.  The  condition  is 
really  a  subglenoid  luxation  but  the  appearance  of  the  patient  is 
quite  different  from  the  usual  subglenoid. 


62 


FRACTURES   AND    DISLOCATIONS 


In  the  subacromial  type  the  head  lies  behind  the  glenoid,  having 
been  driven  across  its  posterior  lip.  The  anterior  portion  of  the 
anatomical  neck  rests  on  the  posterior  edge  of  the  glenoid  and  the 
articular  surface  looks  into  the  infraspinoiis  fossa.  A  prominence 
will  be  noted  on  the  posterior  aspect  of  the  shoulder  while  anteriorly 
the  shoulder  will  be  flattened  and  the  acromion  prominent.  The 
arm  is  usually  shortened  and  more  or  less  fixed  with  tlie  elbow- 
forward.     (See  Figs.  84  and  85.) 


Fig.   85. 


Fig.  84. — Posterior  dislocation  of  riglit  shoulder.  Tlie  humeral  head  projecting  on 
the  posterior  aspect  of  the  shoulder  is  plainly  visible.  Note  shortening  of  arm  and 
change  in  axis. 


Fig.   85. — Palpation    of    displaced   head, 
fingers  and  thumbs. 


Its   position    is   outlined   by   the   two    index 


The  subspinous  type  is  simply  an  exaggeration  of  the  preceding. 
The  head  is  driven  further  backward  on  the  posterior  surface  of 
the  scapula  till  it  comes  to  rest  under  the  spine  of  the  bone.  This 
form  is  very  rare  and  is  usuallj^  the  result  of  great  violence.  The 
symptoms  of  the  subspinous  type  are  those  of  the  subacromial  in 
pronounced  form.  The  arm  is  shortened,  moderately  abducted, 
rotated  inw^ard  and  the  elbow  on  a  plane  anterior  to  the  chest.  The 
trauma  of  the  head  plowing  through  the  tissues  causes  more  or  less 
extravasation  of  blood  and  it  is  usually  only  a  short  time  following 
the  accident  until  the  skin  covering  the  head  of  the  bone  becomes 
ecchymotic.     The   further  the    head   passes   backward   under   the 


V 


DISLOCATIONS   OF    THE    SHOULDER 


63 


Fig.    86. — Another   view   of    the   case   shown   in    Pigs.    84    and    85. 


Fig.  87. — Case  of  complete  avulsion  of  the  upper  extremity.  Case  reported  be 
cause  it  indicates  to  some  extent  the  weakest  points  in  the  various  structures  which  hold 
the  shoulder  together.  Capsule  torn  cleanly  from  the  anatomical  neck  except  over  the 
greater  tuberosity  where  a  triangular  piece  with  a  base  equal  to  the  breadth  of  the 
tuberosity  and  about  three-ciuarters  of  an  inch  to  the  apex.  Supra-  and  infra-spinatous 
muscles  "have  been  torn  from  the  tuberosity  and  scales  of  bone  corresponding  to  the 
insertions  of  the  tendons  have  been  detached.  Tendon  of  teres  minor  torn  across  about 
two  inches  from  its  insertion.  Subscapularis  torn  cleanly  from  lesser  tuberosity.  Small 
shreds  of  the  pectoralis  major  remain  attached  to  the  external  bicipital  ridge,  large  shred 
of  lower  portion  of  this  muscle  (about  three  inches  long)  remains  attached  to  humerus. 
Teres  major  and  latissimus  dorsi  torn  cleanly  from  humerus.  Long  head  of  biceps 
torn  near  origin.  Short  head  torn  a  little  below  the  point  at  which  the  tendon  joins  the 
belly.  About  two  inches  of  the  coraco-brachialis  remains  attached  to  the  humerus 
(transverse  tear  thi-ough  muscular  tissue).  Long  or  middle  head  of  triceps  torn 
transversely  below  tendon,  at  about  level  of  the  surgical  neck.  Median  and  ulnar 
nerves  torn  at  level  of  surgical  neck.  Deltoid  torn  loose  from  clavicular  and  scapular 
origins  with  the  exception  of  the  portion  arising  from  the  acromion.  The  acromion  is 
fractured  transversely  about  three-quarters  of  an  inch  from  the  tip,  the  fragment  re- 
maining attached  to  the  deltoid.  Insertion  of  deltoid  torn  cleanly  from  humerus  leav- 
ing deltoid  eminence  free  from  shreds.  Compound  comminuted  fracture  of  radius  and 
ulna,  and  backward  dislocation  of  wrist.  (The  wrist  was  reduced  before  the  picture 
was  taken.)      Injury  sustained  in  centrifugal  wi-inger  in  laundry.     The  patient  recovered. 


64 


FRACTURES   AND    DISLOCATIONS 


spine  of  the  scapula  the  more  liable  the  arm  is  to  be  fixed  in  its 
new  axis. 

In  the  extremely  rare  upward  luxation  the  arm  is  shortened,  the 
acromion  fractured  and  the  anterior  axillary  fold  raised.  The 
head  of  the  bone  may  be  felt  as  a  pi-ominence  at  the  point  of  the 
shoulder  and  crepitus  is  present  if  the  fragment  of  the  acromion  is 
manipulated. 


Fig.  88. — Example  of  a  snbcoracoid  dislocation  in  a  fleshy  woman.  Tlie  symptoms 
in  obese  persons  are  somewhat  obscured  by  the  adipose  tissue  and  the  condition  has  not 
infrequently  been  overlooked  under  these  circumstances.  If  the  case  is  carefully  in- 
spected,  however,   there  should  be  no  reason  for  failure  in  diagnosis. 

Diagnosis. — There  is  a  good  deal  of  difference  in  the  deformities 
of  the  different  types  of  luxation  occurring  at  the  shoulder  yet 
each  is  characteristic  in  its  way,  and  if  the  surgeon  is  acquainted 
with  the  appearance  of  these  deformities  there  should  seldom  be 
an}'-  difficulty  in  recognizing  the  condition.  There  is  a  nice  pro- 
portion existing  between  the  various  symptoms  in  an  ordinary  snb- 
coracoid or  subglenoid  luxation  and  it  is  of  value  for  the  surgeon 
to  recognize  this  fact.  A  given  amount  of  flattening  of  the 
shoulder  usually  goes  with  a  certain  degree  of  change  in  the 
humeral  axis  and  lowering  of  the  axillary  fold.  This  relation 
between  the  different  objective  symptoms  can  best  be  appreciated 


DISLOCATIONS   OP    THE    SHOULDER 


65 


by  comparing'  the  accompanying  illustrations.  (Figs.  63  to  77.) 
These  symptoms  bear  an  almost  constant  relation  to  each  other  in 
simple  luxations,  but  this  relation  is  frequently  disturbed  when 
fracture  is  present.  In  Fig.  96  flattening  of  the  shoulder  is  shown 
without  any  change  in  the  axis  of  the  humerus.  The  condition  is 
one  of  fracture  of  the  anatomical  neck  with  dislocation  of  the  head 


Fig.  89. — Another  example  of  the  same  condition  as  sliown  in  preceding  illustra- 
tion. The  patient  is  excessively  heavy  yet  the  flattening  of  the  shoulder,  change  in 
humeral  axis  and  lowering  of  the  axillary  fold  are  sufficiently  pronounced  to  recognize 
the   condition  by   inspection   alone. 

of  the  bone.  In  Figs.  117  and  118  the  change  in  the  axis  of  the 
humerus  is  apparent  but  there  is  no  flattening  of  the  shoulder. 
The  condition  is  one  of  fracture  of  the  surgical  neck. 

Nearly  all  the  objective  symptoms  are  less  pronounced,  in  fleshy 
persons,  yet  this  fact  should  be  no  excuse  for  failure  to  diagnose 
the  condition  when  present.  (See  Figs.  88  and  89.)  In  luxa- 
tions of  the  shoulder  the  patient  seldom  makes  any  attempt  to 
support  the  injured  member  with  the  opposite  hand  but  allows  the 
upper  extremity  to  hang  limp  at  the  side  with  a  slight  inclination 
of  the  trunk  forward  and  to  the  same  side.  In  the  exceptional 
cases  in  which  he  does  support  the  arm  the  act  is  casual  and  he 
will  usually  release  it  if  requested.  This  is  quite  different  from 
the  attitude  assumed  by  the  patient  in  the  presence  of  fracture  of 
the  humerus.     He  will  then  grasp  and  support  the  injured  member 


66  FRACTURES   AND   DISLOCATIONS 

witii  the  greatest  care  and  anxiety,  and  can  seldom  he  induced  to 
release  it  Avhen  in  the  standing  or  sitting  position. 

The  diagnosis  nnist  be  made  on  the  symptoms,  and  relief  afiPorded 
the  patient  at  once.  The  X-ray  is  therefore  seldom  of  value  except 
in  verifying  reduction  and  in  the  exclusion  of  complicating  frac- 
tures, after  the  head  has  been  returned  to  the  glenoid  cavity. 

Treatment. — hi  all  forms  of  luxation  llie  indications  are  to 
return  tlic  head  to  the  glenoid  cavity  at  llic  earliest  possible 
moment  and  to  maintain  the  parts  at  rest  until  the  torn  ligaments 
are  healed.  The  methods  of  reduction  vary  with  the  type  of 
luxation. 

The  suhcoracoid  hixafion  is  best  reduced  b}-  -what  is  known  as 
Kocher's  method,  which  consists  of  three  steps  and  is  as  follows: 
"With  the  patient  seated  in  a  straight,  armless  chair  the  surgeon 
grasps  the  elbow  with  his  opposite  hand.  The  elbow  is  then  held 
firmly  against  the  side  while  the  free  hand  secures  the  wrist,  brings 
the  forearm  to  a  right  angle  and  then  carries  it  outward  away  from 
the  median  plane.  This  produces  outward  rotation  of  the  humerus 
and  opens  the  rent  in  the  capsule.     (See  Fig,  91.) 

The  second  step  in  the  manipulation  consists  in  gently  forcing 
the  elbow  forward  and  inward  across  the  chest  while  the  patient's 
hand  is  maintained  in  a  relatively  stationary  position.  (See  Fig. 
92.)  Resistance  is  here  often  encountered  and  should  be  met  by 
an  insistent  springing  motion  in  the  direction  indicated  by  the 
arrow  in  Fig.  94.  It  is  during  this  second  step  that  the  head  of 
the  humerus  usually  slips  back  into  the  socket  Avith  a  distinct  snap. 
When  Kocher's  method  fails  it  is  usually  due  to  the  fact  that  the 
surgeon  is  not  maintaining  outward  rotation  of  the  arm  during 
the  time  the  ell)ow  is  being  brought  forward  across  the  chest.  In 
other  words  the  common  fault  is  in  allowing  the  hand  to  come 
forward  and  inward  at  the  same  time  that  the  elbow  is  being  carried 
across  the  chest.  If  reduction  is  not  accomplished  during  the 
second  step  the  head  is  almost  sure  to  remain  displaced  during  the 
third,  and  the  whole  manipulation  will  have  to  be  repeated. 

The  third  step  consists  in  carrying  the  hand  to  the  opposite 
shoulder  but  is  not  an  essential  part  of  the  manipulation.  Figs. 
91,  92  and  93  not  only  demonstrate  the  proper  steps  and  positions  of 
the  upper  extremity  in  performing  Kocher's  method  but  actually 
show  the  reduction  of  a  suhcoracoid  luxation  done  before  the 
camera.     A  study  of  these  plates  will   give  the  reader  a   better 


DISLOCATIONS   OF    THE    SHOULDER 


67 


Fig.   90. 


Pig.   91. 


Fig.    92. 


Fig.    93. 


Demonstration  of  Koclier's  method  on  a  case  of  subcoracoid  dislocation  of  the  right 
shoulder.  Case  presented  for  treatment  immediately  following  the  accident  with  the 
usual  characteristic  symptoms. 

Fig.  90. — Appearance  of  case  after  being  stripped  to  waist  to  facilitate  examination 
and  reduction. 

Fig.  91.- — First  step  in  Kocher's  method.  Head  is  still  displaced  as  evidenced  by 
the  contour  of  the  shoulder. 

Fig.  92. — Second  step  in  Kocher's  method.  (See  text.)  Note  the  rounded  contour 
of  the  shoulder :  the  head  has  just  been  returned  to  the  glenoid. 

Fig.  93. — Third  step  of  Kocher's  method.      Hand  is  carried  to  opposite  side  of  chest. 


68  FRAOTITRES   AND   DISLOCATIONS 

idea  of  tlit^  iiuiiiipiilatioii  than  rould  \)v  conveyed  by  pages  of 
text. 

Many  surgeons  prefer  the  recumbent  position  in  performing 
Koeher's  method  and  in  some  respects  it  is  more  convenient. 

Not  infrequently  the  i)atient  hindei's  the  sui-geon  by  a  sort  of 
squirming  motion  in  which  he  arclies  tlie  l)ody  toward  the  injured 
shoulder  and  nuiy  even  slich'  off  tlie  tabU'  away  fi-om  the  operator. 
This  may  be  avoicU^d  by  passing  a  hirge  towel  or  slieet  about  the 
chest  and  under  the  dislocated  shoulder.     The  ends  lie  in   front 


Fig.  94. — This  plate  sliow.s  the  essential  aetion  in  Koeher's  method.  The  patient's 
elbow  should  be  carried  iu  the  direction  indicated  by  arrow  CD.  while  the  point  A.  re- 
mains stationarj-  or  is  carried  slightly  away  from  the  median  plane.  Resistance  is 
usually  encountered  and  should  be  met  by  an  insistent,  springing  motion  in  the  direcfion 
indicated  by  the  arrow.  If  the  head  of  the  humerus  does  not  return  to  the  socket  dur- 
ing this  stage  of  the  manipulation  Koeher's  method  will  probably  have  to  be  repeated 
from  the  beginning.  When  the  capsule  has  been  so  extensively  torn  that  no  resistance 
is  encountered  in  carrying  the  elbow  inward  Koeher's  method  will  prove  useless  and 
reduction  will  have  to  be  accomplished  by  horizontal  traction  and  direct  pressure  with 
the  finger  tips  on  the  head  of  the  humerus. 

of  and  behind  the  opposite  shoulder  and  are  used  by  an  assistant 
in  steadying  the  patient.  If  a  slit  be  made  in  a  folded  sheet  and 
the  injured  arm  passed  through  it  we  will  have  an  efficient  means 
of  steadying  the  patient  and  preventing  motion  of  the  scapula. 

If  Koeher's  method  is  properly  employed  it  should  be  possible, 
in  the  usual  uncomplicated  subcoracoid  luxation,  to  accomplish 
reduction  at  the  first  attempt  and  without  the  aid  of  an  anesthetic. 


DISLOCATIONS   OP    TPIE    SHOULDER  69 

The  efficiency  of  Koelier's  metliod  depends  on  the  integrity  of  the 
capsule,  especially  that  portion  known  as  the  coraco-humeral  liga- 
ment, and  when  this  has  been  extensively  torn  the  following  method 
will  generally  succeed. 

Horizontal  extension  and  manipulation. — Raise  the  arm  laterally 
until  it  reaches  the  level  of  the  shoulder,  grasp  the  humerus  just 
above  the  elbow  and  exercise  traction  while  an  assistant  holds  the 
patient  about  the  chest.  Place  the  opposite  hand  in  the  axilla, 
make  gentle  pressure  on  the  head  with  the  finger  tips  in  the  direc- 
tion of  the  socket  and  the  luxation  will  be  reduced  provided  the 
capsule  and  coraco-humeral  ligament  are  extensively  torn.  The 
lower  the  head  rests  on  the  anterior  rim  of  the  glenoid  the  greater 
the  probability  of  this  method  succeeding  after  Kocher's  method 
has  failed.  A  slight  rotary  motion  of  the  humerus  on  its  axis 
during  traction  will  sometimes  facilitate  replacement.  This  method 
will  sometimes  effect  reduction  when  a  displaced  tendon  of  the 
biceps  or  detached  tuberosity  has  caused  Kocher's  method  to  fail. 

Stimson's  method  is  effective  though  not  extensively  used.  It 
requires  a  certain  amount  of  apparatus  and  time  for  its  accomplish- 
ment. The  patient  is  placed  on  a  canvas  cot  and  the  arm  passed 
through  a  slit  previously  made  in  the  canvas.  A  weight  of  about 
ten  pounds  is  attached  to  the  wrist.  Stimson  claims  an  average 
of  about  six  minutes  for  reduction,  during  which  time  the  patient 
is  fairly  comfortable.  This  method  may  be  tried  as  a  last  resort 
before  operating  in  otherwise  irreducible  cases. 

Extetision  outward  and  downward. — This  method  is  probably 
the  oldest  known  and  has  been  in  use  extensively  in  England  and 
America  up  to  recent  years.  Place  the  patient  in  a  recumbent 
position  and  abduct  the  arm  until  it  occupies  an  angle  of  about 
forty -five  degrees  with  the  body;  then  make  traction  in  the  long 
axis  of  the  humerus  while  the  body  is  secured  by  an  assistant.  The 
arm  may  be  rotated  during  traction.  It  has  been  customary  for 
years  to  supplement  the  above  by  placing  the  unbooted  heel  in  the 
axilla  as  a  fulcrum ;  when  this  was  done  additional  force  was  gained 
by  bringing  the  patient's  hand  toward  the  median  plane,  thus 
forcing  the  upper  end  of  the  lever  outward  toward  the  glenoid. 
The  use  of  the  heel  or  any  other  hard  body  in  the  axilla  as  a  fulcrum 
cannot  be  too  strongly  condemned;  such  methods  should  be  dis- 
carded as  a  relic  of  barbarism  for  they  have  outlived  their  useful- 
ness.    No  pressure  in  the  axilla  should  be  used,  which  is  greater 


70  FRACTURES   AND   DISLOCATIONS 

tliaii  can  be  exerted  by  tbe  finger  tips  of  the  surgeon,  and  even  then 
direct  pressure  on  the  nerves  or  vessels  slioubl  l)e  avoided. 

TravlwH  outward  mid  upicard  is  j>ractically  the  same  as  hori- 
zontal traction,  since  elevation  of  tlic  arm  al)ove  tlie  horizontal  is 
accomplished  by  rotation  of  the  scapula  rather  than  l)y  alteration 
in  the  anatomical  relations  of  the  shoulder  joint. 

Great  force  was  advocated  by  some  of  the  older  writers.  Duplay 
cmj^loyed  horizontal  traction  by  means  of  an  elaborate  sj'stem  of 
block  and  tackle,  dynamometer,  etc.  At  the  present  time  there  is 
no  excuse  for  the  employment  of  such  force.  Cases  which  do  not 
respond  to  the  less  violent  and  more  rational  methods  should  be 
treated  b}^  open  incision. 

Sulygletwid  dislocations  of  the  shoulder  can  usually  be  reduced 
by  Kocher's  method  though  the  position  of  the  head  below  the 
glenoid  is  not  as  favorable  for  reduction  as  it  is  in  the  subcoracoid 
form.  The  lower  the  head  lies  on  the  anterior  rim  of  the  glenoid 
the  further  back  the  elbow  should  be  in  starting  the  manipulation. 
In  other  words,  the  lower  the  head  the  greater  the  importance  of 
the  tirst  step  in  Kocher's  method.  In  the  typical  subglenoid  luxa- 
tion (see  Fig.  77)  the  elbow  should  not  be  further  forward  than 
the  midaxillary  line  at  the  beginning  of  Kocher's  method.  During 
the  first  step  the  head  may  be  caused  to  ride  upward  on  the 
anterior  rim  of  the  glenoid  cavity.  The  condition  then  approaches 
the  subcoracoid  type  and  can  be  reduced  as  such.  (See  Figs.  91, 
92  and  93.)  The  capsule  is  often  extensively  torn  in  the  low  sub- 
coracoid and  subglenoid  types  and  in  such  instances  the  head  may 
be  reduced  by  direct  manipulation  with  extension  and  counter- 
extension. 

The  erect  form  of  the  subglenoid  is  extremely  rare  and  the  few 
cases  seen  by  the  author  have  been  easily  reduced  by  extension 
in  the  line  of  the  axis  of  the  displaced  arm  with  digital  pressure  on 
the  head. 

Siihacromial  and  suhspinous  luxations  are  usually  reduced  with- 
out difficulty  by  traction  in  the  axis  of  the  arm ;  axial  rotation  and 
manipulation  may  sometimes  be  necessary  in  addition  to  extension 
and  counter-extension.  The  posterior  forms  are  usually  accom- 
panied by  extensive  laceration  of  the  capsule,  and  hence  their  easy 
reduction. 

Following  reduction  the  X-ray  is  of  value  in  determining  the 
presence  of  fracture  and  the  position  of  the  head.     After  the  head 


DISLOCATIONS   OP    THE   SHOULDER  71 

has  been  returned  to  the  glenoid  cavity  the  following  points  should 
be  noted  to  avoid  overlooking  complications.  Place  the  two  arms 
by  the  side  symmetrically  and  inspect  the  case  from  a  point  a  few 
feet  in  front  of  the  patient  and  again  from  the  side.  This  is 
for  the  purpose  of  recognizing  deformity.  The  distance  between 
the  acromion  and  external  epicondyle  should  be  carefully  measured 
and  compared  with  the  uninjured  side.  If  the  distance  is  lessened 
it  usually  means  complicating  fracture  of  the  humerus.  If  it  is 
increased  it  commonly  indicates  that  the  head  is  not  properly 
seated  in  the  glenoid  cavity.  The  anterior  aspect  of  the  two 
shoulders  should  be  carefully  compared ;  any  undue  prominence 
on  the  injured  side  suggests  fracture  of  the  upper  end  of  the 
humerus  or  the  interposition  of  some  obstructing  tissue  between 
the  head  of  the  humerus  and  the  glenoid.  Undue  prominence  on 
the  anterior  aspect  of  the  shoulder  and  shortening  of  the  arm  are 
symptoms  indicative  of  fracture  and  are  well  shown  in  Figs.  119, 
124  and  127. 

Compare  the  cases  of  fracture  of  the  upper  end  of  the  humerus 
with  the  cases  of  luxation  of  the  shoulder  in  the  accompanying 
illustrations.  Motion,  sensation,  the  condition  of  the  reflexes  and 
the  circulation  should  be  tested  in  the  injured  arm  before  and  after 
reduction. 

The  treatment  of  luxations  of  the  shoulder  will  vary  according 
to  whether  or  not  complications  exist. 

In  simple  cases  the  arm  should  be  immobilized  for  a  period 
sufficiently  long  to  allow  proper  healing  of  the  ligaments  as 
indicated  in  the  after-treatment.     (See  page  79.) 

Displacement  of  the  long  head  of  the  biceps  from  its  groove  may 
sometimes  be  corrected  by  raising  the  arm  well  forward,  even  above 
the  horizontal  and  employing  axial  rotation.  This  complication, 
however,  rarely  occurs  without  fracture  of  the  greater  tuberosity, 
and  under  such  circumstances  the  tendon  and  fragment  are  best 
replaced  and  held  in  position  by  open  incision.  Complicating 
fracture  of  the  upper  end  of  the  humerus  usually  calls  for  opera- 
tive intervention  to  obtain  the  best  results. 

Operative  Treatment. — Operation  is  practically  never  called  for 
to  effect  reduction  of  simple  uncomplicated  cases.  It  is  often  indi- 
cated in  luxations  complicated  by  fracture,  in  injury  to  nerves 
and  vessels,  in  old  unreduced  luxations,  in  habitual  luxations  and 
in  instances  in  which  the  dislocation  is  compound.     The  details  of 


72 


FRACTURES   AND   DISLOCATIONS 


the  operative  procedure  will  depend  largely  on  the  nature  of  the 
complication. 

Fracture  of  the  surgical  neck  of  the  liunierus  complicating  luxa- 


Fig.   95. — McBurney's   hook. 

Hon  is  fortunately  a  rare  condition,  there  being  something  like  150 
reported  cases.  The  older  method  of  treating  this  double  condition 
ufs  to  either  ficc.ire  union  of  the  fracture  fir.'t  and  reduce  the  dislo- 


Fig.  96. — Fracture  of  the  aiiiitomii-Ml  nock  of  th.'  liiuiu'rus  with  displac(?ment  of  the 
humeral  head  beneath  the  coracoid  process.  The  condition  resembles  a  subcoracuid 
dislocation  of  the  shoulder  on  casual  inspection.  The  flattening  of  the  shoulder  is  the 
same  as  seen  in  dislocations  (and  properly  so  since  the  head  is  displaced)  but  it  will 
be  noted  that  the  axis  of  the  humerus  remains  unchanged  and  the  anterior  a.xillary  fold 
is  not  lowered  to  the  extent  seen  in  uncomplicated  subcoracoid  dislocations.  Moreover 
the  patient  supports  the  injured  member  with  the  opposite  hand,  which  is  uncommon  in 
dislocations  of  the  shoulder.  On  manipulating  the  arm  distinct  bony  crepitus  is  elicited 
and  an  abnormal  bony  prominence  is  noted  on  the  anterior  aspect  of  the  shoulder. 
The  displaced  head  could  be  felt  high  in  the  axilla.  An  X-ray  plate  confirmed  the 
diagnosis  of  fracture  of  the  anatomical  neck  with  subcoracoid  displacement  of  the  head. 
Twenty-four  hours  later  ecchymosis  appeared  covering  tlie  anterior  portion  of  the  shoul- 
der. Case  was  operated  seven  days  following  the  injury.  The  displaced  cap  of  bone 
was  pulled  back  onto  the  upper  end  of  shaft  and  wired  in  position.  Outer  and  upper 
portion  of  greater  tuberosity  considerably  comminuted.  Bony  iinion  resulted  and  func- 
tion in  articulation  restored  though  extreme  abduction  remains  slightly  restricted.  Wire 
remains   in    place   at   the   present    time,    five   years   later. 

Photograph  taken  about  fifteen  minutes  following  the  accident.  Fracture  produced 
by  fall  from  bicycle,  the  blow  being  sustained  on  the  outer  aspect  of  the  shoulder. 


DISLOCATIONS   OF    THE   SHOULDER 


73 


cation  later,  or  to  obtain  a  false  joint  at  the  seat  of  the  fracture. 
Both  methods  must,  at  the  present  time,  be  considered  uusurj^ical 
and  obsolete.  McBurney  was  the  first  to  deal  with  this  condition 
in  a  satisfactory  manner,  treating  the  fracture  and  the  dislocation 
at  the  same  time  by  open  incision.  He  devised  a  hook  (see  Fig.  95  j 
by  means  of  which  he  was  able  to  manipulate  the  upper  fragment 
so  as  to  return  the  head  to  the  glenoid,  after  which  the  fragments 
were  adjusted,  and  wired  or  not  as  thought  best.     The  end  of  the 


Fig.   97. 


Fig.    98. 


Fig.  97. — X-ray  of  case  shown  in  Fig.  96  taken  before  operation.  Fracture  of 
anatomical  neck  with  displacement  of  the  head  into  the  axilla  beneath  the  coracoid. 

Fig.  98. — Same  case  after  operation.  Head  has  been  replaced  and  secured  in 
position  with  a  loop  of  wire.  Perfect  apposition  not  possible  because  of  the  crushing 
of  cancellous  tissue   in  the  upper   end  of  the  bone. 


hook  is  inserted  into  a  hole  of  proper  size  drilled  into  the  upper 
fragment,  the  necessary  leverage  being  thus  secured.  In  fracture 
of  the  anatomical  neck  (which  is  even  more  unusual  than  fracture 
of  the  surgical  neck)  the  McBurney  hook  is  of  little  service  in 
reducing  a  dislocation  of  the  upper  fragment.  The  cap  of  bone 
must  be  handled  by  means  of  tenacula  because  of  its  friable,  can- 
cellous structure,  and  if  reduction  is  impossible  should  be  excised. 
Very  serviceable  joints  frequently  result  after  removal  of  the  head. 


74 


FRACTURES   AND   DISLOCATIONS 


Fig.   99. — Same  case  after  operation  and  recovery.      Picture  taken  about  eight  weeks 
ifter  operation. 


Pigs.  100  and  101. — Stereoscopic  view  of  a  comminuted  fracture  of  the  anatomical 
nock  of  the  humerus  with  subglenoid  dislocation  of  the  humeral  head.  The  arrow  points 
to  the  displaced  head. 


DISLOCATIONS   OP   THE    SHOULDER 


75 


When  the  head  can  be  replaced  it  is  often  found  necessary  to  secure 
it  in  position,  which  is  most  easily  accomplished  by  wire  (see  Fig. 
98).  A  peculiar  point  to  be  noted  here  is  that  the  head  of  the 
humerus  almost  never  suffers  necrosis,  even  though  the  upper  frag- 


Fig.    102. — Siihcoracoid  dislocation   complicated  by  fracture  of  the  greater  tuberosity. 
Fragment  displaced.     Arrows  point  to  lines  of  fracture. 


ment  includes  only  the  articular  surface ;  and  it  is  here  that  one 
might  expect  necrosis  since  the  upper  fragment  is  apparently 
cut  off  from  its  blood  supply. 

Either  of  the  tuberosities  may  he  fractured  in  dislocations  of  the 


76 


FRACTURKS    AND    DISLOCATIONS 


sli(>uhl(  r  and  may  lie  displaced  in  the  line  of  pull  of  tlie  attached 
muscles.  Reposition  l)y  open  incision  and  fixation  l)y  nutans  of  a 
loop  of  silver  w'in^  will  he  found  n)ost  satisfactoiy. 

Two  modes  of  approach  are  employed,  one  incision  (the  external) 
passes  through  the  deltoid  on  the  outer  side  of  the  shoulder,  and 
the  other  (the  anterior)  is  made  in  the  sulcus  hetween  the  deltoid 
and  pectoralis  major.  In  making-  the  external  incision  the  circum- 
flex nerve  may  he  encountered  in  the  lower  part  of  the  wound  and 
should  be  avoided.  In  the  low  forms  of  the  subcoracoid  or  the 
subglenoid  dislocations  some  of  the  nerves  of  the  brachial  plexus 
or  even  the  axillai-y  artery  may  lie  in  fi'ont  of  the  head,  and  in 
nuiking-  the  anterior  incision  the  surgvon  should  be  on  the  lookout 
for  these  structures. 

Injuries  to  the  liracMal  plexus  call  for  operative  intervention, 
Init  before  this  is  attempted  a  careful  neurological  examination 
should  be  made  to  determine  as  accurately  as  possible  the  extent 


Fig.  inn. 


Fig.    104. 

Figs.    103   and   104. — Two    views    of    contracture    of    hand    following    dislocation    of 
shoulder   with  injury   to  brachial  plexus. 


of  the  damage  and  the  region  of  the  plexu.s  injured.  It  should 
be  remembered  that  the  upper  part  of  the  plexus  may  be  torn  by 
the  pull  on  the  nerves  when  the  humerus  is  disi)laced  downward. 
Nothing  in  an  operative  way  is  indicated  in  instances  in  which  one 


DISLOCATIONS   OP    THE    SHOULDER  77 

or  more  of  the  nerves  are  bruised  or  stretched  but  when  laceration 
occurs  the  ends  should  be  approximated  and  sutured  together.  The 
patient  should  be  fully  appraised  of  the  doubtfulness  of  the 
prognosis  under  such  circumstances. 

Rupture  of  the  axillary  artery  or  vein  with  the  development  of 
an  axillary  hematoma  (frequently  of  the  pulsating  type,  when  the 
artery  is  torn)  calls  for  immediate  operative  intervention.  The 
artery  is  temporarily  compressed  against  the  first  rib  to  control 
hemorrhage  and  an  incision  made  to  expose  the  vessel  in  the  region 
of  the  injury.  Suture  of  the  injured  vessel  is  rarely  possible. 
Ligation  will  be  indicated. 

Old  luxations  of  the  shoulder  may  in  some  instances  be  reduced 
by  manipulation,  even  after  the  head  has  been  out  of  the  glenoid 
for  four  or  five  months,  though  the  longer  the  dislocation  has  existed 
the  less  the  chance  of  reduction  without  open  incision  (see  Fig. 
105).  Great  force  should  not  be  used  in  attempting  to  reduce 
these  old  dislocations  because  of  the  liability  of  injury  to  vessels 
or  nerves  or  of  producing  fracture  of  the  humerus.  The  fibrous 
tissue  surrounding  the  head  may  involve  the  brachial  plexus  or 
axillary  artery,  and  when  the  head  is  forcibly  returned  to  the 
glenoid  these  structures  may  be  torn.  AVhen  gentle  manipulation 
does  not  produce  the  desired  results  open  incision  should  be 
resorted  to.  The  anterior  incision  is  better  adapted  to  freeing  the 
head  from  the  fibrous  tissue  surrounding  it,  while  the  external 
incision  affords  better  access  to  the  glenoid  cavity  for  the  removal 
of  fibrous  tissue  which  so  frequently  fills  it.  After  the  parts  have 
been  exposed,  the  head  liberated  and  the  glenoid  cavity  cleaned 
out  there  should  be  little  difficulty  experienced  in  returning  the 
head  to  its  normal  position.  Old  rents  in  the  capsule  should  be 
approximated  by  suture  after  the  edges  have  been  scarified.  AVhen 
the  incision  enters  the  joint  the  divided  capsule  should  be  closed 
with  catgut  after  reduction  has  been  accomplished.  Provision  for 
the  escape  of  blood  which  may  subsequently  ooze  into  the  wound 
and  joint  should  be  made,  so  that  there  may  be  no  dead  spaces  to 
favor  infection.     (See  "Open  Treatment  of  Fractures,"  page  754.) 

Recurrent  dislocations  sometimes  become  so  frequent  that  the 
usefulness  of  the  arm  is  much  impaired,  and  the  only  relief  is 
through  operative  intervention,  Avhicli  consists  in  repairing  the  rent 
in  the  capsule  and  in  plicating  the  same  when  necessary. 

Compound  luxations  of  the  shoulder  are  extremely  rare.     The 


78 


FRACTURES  AND  DISLOCATIONS 


Figs.  105,  106  and  107. — 'ilirce  views  ol  an  old  subcoracoid  dislocation  of  left 
shoulder  of  nearly  five  months'  standing  at  the  time  the  photographs  were  taken.  This 
dislocation  was  reduced  at  the  first  attempt  by  means  of  Kocher's  method  with  the 
patient  in  the  standing  position,  which  goes  to  show  that  cases  of  long  standing  are  not 
necessarily   operative  cases. 


DISLOCATIONS   OF    THE    SHOULDER  79 

treatment  of  these  conditions  is  essentially  operative  and  should  be 
carried  out  according  to  the  principles  laid  down  in  the  chapter  on 
"Treatment  of  Compound  Fractures  and   Luxations,"   page  789. 


Pig.  108. — This  case  is  a  stiikuij;  example  of  recurrent  dislocation  of  tlie  shoulder. 
The  photograph  was  taken  imuiediateh  following  reduction  of  the  seventy-second  dislo- 
cation of  the  patient's  left  shoulder.  The  use  of  the  left  arm  is  much  impaired  as  the 
patient  is  continually  guarding  against  the  positions  which  he  has  learned  from  experi- 
ence are  likely  to  produce  displacement.  The  condition  has  extended  over  a  period  of 
many  years  and  as  a  result  of  the  disturbed  function  the  muscles  of  the  left  shoulder 
show  a  very  slight  atrophy. 

After-Treatment. — In  the  uncomplicated  cases  of  dislocation  of 
the  shoulder  the  arm  should  be  immobilized  for  a  period  of  three 
weeks,  but  under  no  consideration  should  we  fail  to  employ  passive 
motion  as  soon  as  the  acute  traumatic  reaction  has  subsided. 
This  will  usually  be  at  the  end  of  five  or  six  days.  The  arm  should 
be  fixed  to  the  side  and  the  forearm  carried  in  a  sling.  A  con- 
venient method  is  to  sew  the  sleeve  of  the  undershirt  to  the  body  of 
the  garment.  This  prevents  the  arm  from  being  carried  far 
enough  away  from  the  body  to  strain  the  capsule.  In  performing 
passive  motion  the  surgeon  should  avoid  external  rotation  and 
extreme  abduction  since  the  former  tends  to  open  the  rent  in  the 
capsule,  while  the  latter  causes  the  injured  portion  of  the  capsule 


80  FRACTURES   AXD    IMsr.OCATIONS 

to  be  stretclu'd  across  the  head  of  the  bone.  The  duration  of  ininio- 
bilization  should  be  governed  by  the  extent  of  the  eapsuhir  lacera- 
tion. Prolonged  immobilization  without  passive  motion  will  result 
in  more  or  less  permanent  loss  of  mobility,  wliile  on  the  other  liand, 
unrestricted  use  of  the  member  following  reduction  will  almost 
surely  be  followed  by  a  condition  of  recurrent  dislocation. 

When  fracture  complicates  dislocation  the  arm  should  be  innno- 
bilized  as  in  sim})le  fi-acture  of  the  humerus,  from  four  to  si.\  weeks, 
until  union  takes  ])lace.  Passive  motion  under  these  circumstances 
is  not  permissible  prior  to  union,  though  careful  massage  may  be 
begun  as  soon  as  the  traumatic  reaction  has  subsided.  If  it  is 
found  that  the  joint  is  nuich  restricted  in  its  motion  after  union  is 
firm  we  may  break  up  the  joint  adhesions  by  passive  motion,  using 
an  anesthetic  if  necessary.  This  should  not  be  attempted  inside  of 
two  months  following  the  injury,  and  only  then  when  the  X-ray 
shows  a  good  callus  at  the  seat  of  fracture.  (See  "Treatment  of 
Fractures  of  the  T^j^pei"  End  of  the  Humerus,"  page  97.) 

Prognosis. — In  the  simple  uncomplicated  elislocation  (especially 
of  the  subcoracoid  type)  the  restoration  of  function  should  be 
practically  complete  provided  passive  motion  is  instituted  early 
and  the  patient  is  prevented  from  using  the  arm  before  the  liga- 
ments have  healed.  The  prognosis  is  rendered  worse  according  to 
the  presence  and  nature  of  complications.  In  injury  to  the  axil- 
lary vessels  collateral  circulation  is  usually  established  if  the  mem- 
ber is  properly  cared  for.  Injury  to  the  brachial  plexus  or  some 
of  its  branches  is  not  exceptionally  rare  and  deserves  a  most  guarded 
prognosis.  It  is  true  that  injury  to  nerves  has  occurred  during 
reduction,  especially  in  cases  in  which  the  heel  has  been  used  as  a 
fulcrum  in  the  axilla,  but  on  the  other  hand  the  surgeon  not  infre- 
quently has  been  blamed  for  paralyses  which  were  produced  at 
the  time  of  the  accident  and  for  which  he  was  in  no  way  responsible. 
These  unfortunate  circumstances  demonstrate  the  value  of  exam- 
ining the  condition  of  the  reflexes  and  of  motion  and  sensation  in 
the  arm  before  any  attempt  at  reduction  is  made.  Pressure  on  the 
nerves  by  the  head  of  the  bone  is  usually  accompanied  by  transitory 
symptoms  and  complete  recovery.  Laceration  of  the  nerves  is 
followed  by  permanent  paralyses  unless  the  nerve  ends  are  united. 
Operation  renders  the  prognosis  better,  though  recovery  is  usually 
prolonged  and  often  incomplete,  especially  if  the  condition  is  of 
long  standing  at  the  time  of  operation.     In  old  unreduced  luxations 


DISLOCATIONS   OP   THE    SHOULDER  81 

the  patient  sometimes  develops  surprisingly  good  us(;  of  the  arm 
as  years  go  on.  The  betterment  of  the  condition  by  operation  is 
usually  quite  gratifjdng.  Most  recurrent  luxations  can  be  com- 
pletely cured  by  operation.  Compound  luxations  are  usually  pro- 
duced only  by  great  trauma  and  the  prognosis  will  depend  on  the 
injury  sustained  by  the  surrounding  soft  tissues  and  the  subsequent 
development  of  infection.  The  prognosis  of  these  luxations  is 
grave  though  modern  operative  treatment  has  improved  the 
outlook  greatly. 


CHAPTER  YII. 

FRACTURES  OF  THE  UPPER  END  OF  THE  HUMERUS. 

Surgical  Anatomy. — The  upper  end  of  the  humerus  is  deeply 
seated  and  extremely  difficult  of  palpation  unless  dislocated.  It 
will  be  noted  that  the  normal  lateral  prominence  of  the  shoulder 
is  due  to  the  head  of  the  humerus  beneath  the  deltoid  muscle,  and 
not  to  the  acromion.  The  upper  extremity  of  the  bone  is  composed 
of  cancellous  tissue,  as  shown  in  Fig-.  110,  there  being  only  a  thin 
laj^er  of  compact  bone  on  the  surface.  The  manner  in  which  the 
compact  tissue  of  the  shaft  grows  rapidly  thinner  as  the  end  of  the 
bone  is  approached  is  well  shown  in  the  section  of  bone  just  referred 
to  in  Fig.  110.  The  internal  structure  is  deserving  of  careful  study 
since  it  explains  some  of  the  deformities  and  the  variations  in  the 
types  of  fracture  occurring  at  different  levels.  In  addition  the 
surgeon  should  appreciate  the  internal  structure  as  well  as  the 
surface  form  in  performing  operations  for  the  direct  fixation  of 
fragments.  The  attachment  of  the  capsule  corresponds  to  the 
anatomical  neck  except  on  the  inner  aspect  of  the  bone  where  it  is 
attached  a  little  below  the  line  of  the  neck.  The  nuiscles  attached 
to  the  upper  end  of  the  bone  are  important  in  explaining  the  de- 
formities occurring  in  the  presence  of  fracture.  The  muscles 
inserted  into  tlie  greater  tuberosity  are,  from  before  backward,  the 
supraspinatus,  infraspinatus  and  teres  minor.  These  three  muscles 
arise  from  the  supraspinous  fossa,  infraspinous  fossa  and  axillary 
border  of  the  scapula  respectively,  and  pass  in  almost  straight  lines 
to  their  insertions  into  the  greater  tuberosity.  These  muscles  when 
unopposed  by  the  weight  of  the  limb  and  the  muscles  inserted  into 
the  shaft,  tend  to  produce  outward  rotation  and  abduction  of  the 
upper  fragment.  The  subscapularis  arises  from  the  subscapular 
fossa  and  passes  directly  to  its  insertion  into  the  lesser  tuberosity. 
When  unopposed  it  tends  to  produce  inward  rotation.  It  lies  to  the 
inner  side  of  the  joint  and  is  in  contact  with  the  capsule.  When 
the  shaft  is  separated  from  the  upper  end  of  the  bone  the  muscles 
attached  in  the  region  of  the  bicipital   groove   tend  to   produce 

82 


FRACTURES   OF    UPPER   END   OF    HUMERUS  83 

inward  displacement  of  the  upper  end  of  the  lower  fragment. 
These  muscles  are  the  pectoralis  major,  teres  major  and  latissimus 
dorsi. 

Fractures  of  the  upper  end  of  the  humerus  may  show  great  varia- 
tion, yet  in  most  instances  the  injury  will  conform  more  or  less 
accurately  to  one  or  more  of  the  following  types:  fracture  of  the 


Fig-.    109.  Fig.    110. 

Fig.  109. — Upper  end  of  humerus  in  young  subject.  Note  position  of  epiphyseal 
line.      E..   epiphysis;    E.L.,  epiphyseal   line;    1).,  diaphysis. 

Fig.  110. — Coronal  section  of  same  bone.  M.,  metaphysis.  Note  the  manner  in 
which  the  diaphysis  projects  into  the  epiphysis  and  the  relative  distribution  of  can- 
cellous tissue. 

anatomical  neck,  fracture  of  the  tuberosities,  fracture  of  the  surgi- 
cal neck  and  separation  of  the  epiphysis. 

Fracture  of  the  anatomical  neck  occurs  in  middle  and  old  age  and 
is  usually  the  result  of  direct  violence.  The  line  of  fracture  seldom 
corresponds  exactly  with  the  anatomical  neck.  The  most  usual 
variations  of  fracture  of  the  anatomical  neck  are :  fracture  of  the 


84 


FRACTURES   AND   DISLOCATIONS 


anatomical  neck  through  its  inner  lialf  or  two-thirds  (the  outer 
l)ortion  of  the  fracture  being  so  placed  as  to  include  the  greater 
tuberosity  with  the  upper  fragment), — splitting  of  the  upper  end 
of  the  bone  with  fi-acture  of  the  anatomical  neck  and  impaction  of 


Fig.    111. — R<>nti;(iiuLrram  of  shoulder  of  child  nine  years  of  age. 
of  the  epiphyseal   cartilage   and   compare  with  Figs.    109   and    110. 


Xote  the  relations 


the  head  into  and  between  the  tuberosities, — fracture  of  the 
anatomic  neck  in  its  outer  half  with  a  portion  of  the  inner  side  of 
the  shaft  attached  to  the  upper  fragment.  The  line  of  fracture 
very  rarely  follows  the  anatomical  neck  tliroughout,  but  when  it 


FRACTURES   OP    UPPER   END   OF    HUMERUS 


85 


does  the  upper  fragment  is  left  free  from  muscular  and  ligamentous 
attachments  and  is  as  likely  to  be  displaced  in  one  direction  as 
another.  Fracture  of  the  anatomical  neck  is  usually  accompanied 
by  more  or  less  crushing  of  the  internal  cancellous  tissue  in  the 


Fig.  112. — Fracture  of  ajiatomical  neck  of  humerus.  Fracture  in  this  region 
seldom  follows  tl^e  anatomical  neck  througliout  but  inchides  tlie  upper  portion  of  tlie 
greater  tuberosity  with  the  head,   as  in  this   case. 


upper  end  of  the  bone  and  impaction  of  the  fragments  is  not  un- 
common. 

Fractures  of  the  tuberosities  as  isolated  injuries  are  extremely 
rare.  .  They  are  most  commonly  associated  with  dislocations  of  the 
shoulder  and  may  occur  with  fracture  of  either  the  anatomical  or 


86 


FRACTURES   AND   DISLOCATIONS 


surgical  iiee-k.  Avulsion  of  a  scale  of  boue  from  the  greater  tuber- 
osity corresponding  to  the  insertions  of  one  or  more  of  the  attached 
muscles  has  been  reported  in  a  few  cases  and  is  the  result  of  muscu- 
lar action.  Undoubtedly  this  condition  has  existed  in  many  cases 
and  been  mistaken  for  a  "sprain."     Isolated  fracture  of  the  lesser 


Fig.    113. — Fracture  of  surgical  neck  of   humerus.      Good   position  of  fragments. 


tuberosity  is  even  more  rare  than  fracture  of  the  greater  tuberosity. 
It  is  known  to  have  been  avulsed  by  overaction  of  the  subscapularis. 
Fracture  of  the  lesser  tuberosity  is  most  often  seen  as  a  complica- 
tion of  dislocations  of  the  shoulder,  especially  those  of  the  posterior 
variety.     The  fragment  is  displaced  by  the  pull  of  the  attached 


FRACTURES   OP    UPPER   END   OP    TirjMERIIR 


87 


muscle  and  usually  lies  in  the  axilla  internal  to  and  below  the 
head. 

Fractures  of  the  surgical  neck  are  much  more  common  injuries. 
The  surgical  neck  is  that  portion  of  the  bone  between  the  epiphy- 
seal cartilage  and  the  insertions  of  the  pectoralis  and  teres  major. 
When  fracture  occurs  in  this  region  the  lower  fragment  will  be 
displaced  inward  by  the  pull  of  the  pectoralis  major,  latissimus 
dorsi  and  teres  major  and  overriding  will  be  effected  by  the  action 


Fig.    114. — Fractur, 
fracture. 


iical    neck    with    considerable    comminution    along   line    of 


of  the  biceps,  triceps,  deltoid  and  coraco-brachialis.  The  upper 
fragment  will  be  controlled  by  the  muscles  attached  to  the  tuberosi- 
ties and  is  usually  displaced  forward  and  may  be  abducted  or 
adducted.  The  lower  fragment  may  be  driven  upward  into  the 
upper  fragment,  or  the  serrated  surfaces  sufficiently  engaged  to 
partially  or  completely  oppose  the  displacing  action  of  these 
muscles. 

Pronounced  inward  displacement  of  the  upper  end  of  the  lower 
fragment  may  produce  injury  to  vessels  and  nerves.     The  lesions 


8»  FRACTURES   AND   DISLOCATIONS 

■will  be  similar  to  those  already  incut ioiicd  as  occasionally  coiiipli- 
catiug  dislocations  of  the  shoulder. 

Epipliyseal  separation  of  the  upper  end  of  the  humerus  is  not 
an  uncommon  accident.  The  upper  epiphysis  of  the  humerus  is 
ossified  from  two  centers,  one  for  the  head  and  one  for  the  greater 
tuberosity.  Occasionally  an  additional  center  is  seen  for  the  lesser 
tuberosity.  The  ossific  center  for  the  head  is  present  at  birth,  that 
for  the  greater  tuberosity  is  tirst  seen  during  the  third  year.  When 
the  lesser  tuberosity  is  ossified  by  a  separate  center  it  is  usually 
not  seen  until  the  fifth  year.  The  head  and  greater  tuberosity 
are  fused  at  the  sixth  year  so  that  the  epiphysis  is  one  piece  of  bone. 


Fig.    115. — Fracture    of    surjiical    mn-k   with    deformity.      Coiniiiimition    of   upper    frao:ment. 

The  epiphysis  joins  the  shaft  at  about  the  twentieth  year.  Sep- 
aration of  the  epiphysis  may  occur  at  any  time  prior  to  the  twentieth 
year,  but  is  most  commonly  seen  from  the  ninth  to  the  seventeenth 
years.  The  position  of  the  epiphyseal  cartilage  is  well  shown  in 
Figs.  110  and  111.  It  will  be  noted  that  the  cartilage  is  roughly 
horizontal  but  that  the  center  is  much  higher  than  the  margins. 
This  is  i)robably  due  to  the  fact  that  the  epiphysis  is  ossified  from 
two  centere.  The  conical  conformation  of  the  end  of  the  diaphysis 
accounts  for  the  fact  that  recurrence  of  deformity  is  seldom  seen 
following  reduction  of  an  epiphyseal  separation  in  this  region. 
The  joint  cavity  may  be  opened,  but  more  often  is  not.  When  the 
diaphysis  is   displaced  the   deformity  is  similar  to  that  seen  in 


FRACTURES   OF    UPPER   END    OF    HUMERUS  89 

fractures  of  the  surgical  neck ;  that  is,  the  uj)per  end  of  the  shaft 
is  pulled  inward  by  the  action  of  the  pectoralis  major,  teres  major 
and  latissimus  dorsi  and  raised  by  the  muscles  of  the  arm. 

Etiology. — Fractures  of  the  upper  end  of  the  humerus  are  the 
result  of  direct  and  indirect  violence.  Fracture  af  the  surgical 
neck  is  the  most  common  break  in  this  region.  Fracture  of  the 
anatomical  neck  occurs  mostly  in  the  aged.  Epi])hyseal  separations 
are  seen  only  in  children  and  adolescents.  Various  types  of  frac- 
ture of  the  upper  end  of  the  humerus  are  occasionally  seen  as  com- 
plications of  luxations  of  the  shoulder. 


Fig.    116. — Transverse  fracture  of  the  surgical  neck  with  pronounced   deformity. 

Symptoms. — The  symptoms  accompanying  fracture  of  the  upper 
end  of  the  humerus  will  vary  according  to  the  nature  and  severity 
of  the  lesion.  If  the  fragments  are  free  the  symptoms  will  usually 
be  pronounced.  When  impaction  exists  the  symptoms  may  be  so 
slight  at  first  that  the  patient  continues  to  use  the  part,  although 
there  is  always  more  or  less  pain  and  discomfort.  Swelling  about 
the  shoulder  is  almost  constant  and  an  abnormal  prominence 
anteriorly  (see  Figs.  119  and  124)  usually  accompanies  fractures 
in  this  region.  Function  is  completely  lost  in  unimpacted  cases 
but  is  often  only  partially  so  when  the  fragments  are  impacted. 
Pain  is  constant  though  the  degree  is  quite  variable.  It  is  always 
more  severe  in  unimpacted  cases.  Eccliymosis  usualh''  develops 
within  twelve  to  twenty-four  hours  following  the  fracture.     The 


90 


FRACTURES   AND    DISLOCATIONS 


attitude  of  the  patient  is  usually  characteristic.  The  upper  part 
of  the  trunk  is  inclined  forward  and  toward  the  injured  side,  and 
the  injured  arm  is  supported  with  the  opposite  liand.     This  attitude 


Figs.  117  and  118. — Two  views  of  recent  fracture  of  the  surgical  neck  of  the 
humerus.  Note  the  abnormal  prominence  on  the  anterior  aspect  of  the  shoulder,  also 
change  in  a.xis  of  humerus  which  i.s  not  accompanied  by  Hattening  of  the  shoulder  as 
seen  in  dislocations.  Yery  slight  shortening  of  the  arm  present.  Note  how  patient 
grasps  the  injured  member  with  opposite  hand  (an  attitude  seldom  seen  in  dislocations  of 
the   shoulder).      Picture  taken   about  half   an   hour   following  the   accident. 


Fig.  119. — Same  case  seen  in  the  recumbent  position.  Note  that  the  abnormal 
prominence  on  the  anterior  aspect  of  the  shoulder  is  not  changed  bj'  the  patient's  lying 
down. 

is  usually  not  assumed  in  isolated  fracture  of  one  of  the  tuberosities 

but  only  when  there  is  solution  of  continuity  in  the  humeral  shaft. 

In  fracture  of  the  anatomical  neck  impaction  is  not  uncommon 

and  accordingly  the  symptoms  may  not  be  severe.     Pain  is  present 


FRACTURES   OF   UPPER  END   OF    PIUMERUS  91 

on  moving  the  shoulder.  Swelling  is  constant.  Abnormal  mobility 
will  be  present  unless  the  fracture  is  impacted  but  the  proximity  of 
the  shoulder  joint  to  the  point  of  false  motion  often  renders  the 
condition  difficult  of  recognition.  Deformity  may  be  present  but 
is  much  less  common  than  is  the  case  in  fracture  of  the  surgical 
neck.  Slight  flattening  of  the  shoulder  may  be  noted  but  is  uncom- 
mon. The  humeral  neck  is  usually  thickened.  Alteration  in  the 
humeral  axis  may  be  apparent  in  the  uncommon  cases  in  which 
there  is  lateral  displacement  of  the  fragments. 

In  fracture  of  the  greater  tuberosity  the  power  of  outward  rota- 
tion will  be  diminished  and  motion  of  the  shoulder,  especially  rota- 


Fig.    120. — X-ray   of   case   shown   in   Figs.    117,    118    and    119.      Fracture   of    surgical 
neck  of   humerus. 

tion,  will  be  attended  by  pain.  Swelling  is  variable.  Local  tender- 
ness is  constant.  By  applying  a  stethoscope  to  the  shoulder  and 
rotating  the  humerus  it  may  be  possible  to  detect  crepitus  which 
would  otherwise  escape  recognition.  The  normal  joint  sounds  and 
those  occurring  in  arthritis  should  not  be  confused  with  true 
crepitus.  It  may  in  some  cases  be  possible  to  palpate  the  displaced 
fragment.  7n  fracture  of  the  lesser  tuberosity  the  power  of  internal 
rotation  will  be  lost  or  lessened  and  it  may  be  possible  to  palpate 
the  displaced  fragment  in  the  axilla,  below  and  to  the  inner  side  of 
the  humeral  neck. 


92 


FRACTURES   AND   DISLOCATIONS 


/;(■  fracture  of  the  siiri/icdJ  iifck  tlic  syiiii)toins  ;ire  more  i)ro- 
nounced  and  constant.  Inipaction  is  rare,  pronounced  defoi-niity  is 
the  rule.  Tlie  upper  end  of  the  lower  fragment  is  usually  displaced 
upward,  foi'ward  aiul  inwai'd.  or  upwai'd  and  inwai'd.  The  more 
pronounced  the  lateral  (lisi)laci'ment  the  more  apparent  will  be  tlie 
cliauiic  in  tlu'  axis  of  the  humeral  shaft.  Pain  is  usually  severe  and 
the  sult'erinti'  gi'catly  inci'cased  hy  motion  of  the  shouhler.  Injuries 
to  nerves  and  vessels  ai'c  unusutd  tlioug'h  the\'  are  more  common  in 
this  fi'actui'e  than  in  any  other  occui'rin^'  in  Ihe  up])ei'  end  of  the 
liumerus.    jind    Ihe    acc()m|)anyiiiL;    symptoms    nvv   similar    to    those 


Fig.    121 


Figs.  121  and  122.- — Fracture  of  surgical  neck  of  humerus  twelve  hours  after 
injury.  Note  the  undue  prominence  of  the  shoulder  anteriorly  which  is  greater  than 
would  be  present  in  simple  swelling  of  the  shoulder  following  sprain.  Note  also  tlie 
ecchymosis  which  almost  never  follows  dislocation.  Note  the  attitude  of  the  patient  in 
grasping  the  in.iured  member  with  the  opposite  hand.  In  dislocations  the  patient  seldom 
makes  any  attempt  to  support  the  injured  member  but  in  fractures  of  this  region  it  is 
often  difficult  to  get  him  to  let  go  of  it  even  for  an  instant.  Injury  sustained  in  this 
case  by  blow  on  the  upper  and  outer   a.spect  of  the   arm.      Patient  about  60  years  of  age. 


described  under  "Dislocations  of  the  Shoulder,"  page  76.  Pain, 
mobility,  crepitus,  loss  of  function,  swelling,  ecchymosis  and 
deformity  are  more  pronounced  and  characteristic  in  fracture  of 
the  surgical  neck  than  they  are  in  any  other  fracture  occurring  in 
the  upper  end  of  the  humerus.  The  accompanying  illustrations  will 
give  the  reader  a  good  idea  of  the  usual  clinical  picture  accompany- 
ing fractures  of  the  surgical  neck. 

In  epiphyseal  separations  of  the  upper  end  of  the  humerus  the 
symptoms  are  similar  to  those  seen  in  fractures  of  the  surgical  neck. 
Displacement,  however,  is  not  as  constant,  loss  of  function  is 
variable,  and  crepitus  soft  and  cartilaginous.     Separation  of  the 


FRACTURES    OP    UPPER   END    OF    HdMERUS 


93 


Fig.   123. — Rontgenogram   of   case   shown   in   Figs.    121    and    122. 


Fig.  124. — Low  fractui'e  of  sargical  neck  of  right  humerus.  Note  the  shortening 
of  the  arm  on  injured  side.  The  lower  end  of  the  upper  fragment  is  displaced  forward, 
producing  the  abnormal  prominence  indicated  by  arrow,  while  the  lower  fragment  is 
displaced  upward.  Note  the  tight  grasp  on  the  fingers  of  the  injured  member.  This 
attitude  was  assumed  even  after  the  patient  was  requested  to  release  his  hold  on  the 
forearm  higher  up.  (See  Dia-gnosis.)  Only  slight  change  in  humeral  axis.  Photograph 
taken  about  three  hours  following  injury.  (Note  evidence  of  syphilis  in  nose  and  com- 
pare with  Figs.  463  to  46.5,) 


94 


FRACTURES   AND    DISLOCATIONS 


Pig.  125. — Same  case  (Fig.  124)  seen  in  recumbent  position.  Note  that  the  change 
in  position  does  not  influence  the  prominence  on  the  anterior  aspect  of  the  shoulder. 
It  is  easy  to  see  that  the  prominence  indicated  by  arrow  is  produced  by  forward 
displacement  of  the  upper  fragment  since  the  axis  of  the  arm  and  therefore  of  the  lower 
fragment  is  only  slightly  altered.  Compare  with  Fig.  127,  in  which  both  fragments  are 
angulated. 


Fig.    127. 


Figs.  126  and  127. — Youth,  age  15  years.  Fell  about  fifteen  feet  and  struck  on 
left  shoulder.  Pain  and  disability  present  on  rising  from  ground.  Promptly  attended 
by  physician  who  diagnosed  dislocation  and  treated  same  by  Kocher's  method.  Case 
seen  by  another  physician  a  few  days  later.  First  seen  by  author  about  three  weeks 
following  injury  when  photographs  were  taken.  Note  prominence  on  anterior  aspect 
of  shoulder  and  shortening  of  arm,  both  signs  indicative  of  fracture.  Pen  outline  on 
arm  indicates  the  positions  of  the  fragments  as  revealed  by  palpation.  Arm  can  be 
carried  only  a  short  distance  forward  because  of  the  deformity  interfering.  Diagnosis 
confirmed  by  X-ray.      (See  Fig.   128.) 


FRACTURES   OF    UPPER   END   OF    HUMERUS  95 

upper  epiphysis  may  occur  without  displacement  and  the  loss  of 
function  may  be  only  partial.  Under  these  conditions  the  surgeon 
may  fail  to  recognize  the  nature  of  the  injury.  When  deformity 
is  present  the  upper  end  of  the  diaphysis  is  usually  displaced  for- 
ward and  inward  and  on  examination  of  the  shoulder  the  lesion 
is  noted  at  a  higher  level  than  that  seen  in  fracture  of  the  surgical 
neck.  The  anterior  aspect  of  the  shoulder  is  characteristic.  The 
prominence  caused  by  the  upper  end  of  the  diaphysis  can,  as  a  rule, 
be  appreciated  by  inspection  alone. 

An  epiphyseal  separation  without  deformity  may  easily  escape 
recognition  immediately  following  the  injury.     If  the  shoulder  is 


Fig.    128. — X-ray  of  case  shown  in  Figs.   126   and  127. 

not  immobilized  subsequent  strain  is  likely  to  produce  displacement 
and  the  characteristic  deformity,  together  with  the  accentuation  of 
the  symptoms,  discloses  the  nature  of  the  injury. 

Diagnosis. — The  diagnosis  of  fractures  of  the  upper  end  of  the 
humerus  is  based  on  the  symptoms  just  enumerated  and  when 
these  are  typical  there  should  be  little  difficulty  in  determining  the 
nature  of  the  injury.  A  thorough  and  systematic  examination  of 
the  shoulder  should  be  made  in  every  case  and  the  possibility  of 
associated  fractures  of  the  clavicle  and  of  dislocations  of  the 
shoulder  and  acromio-clavicular  joint  should  be  kept  in  mind. 

With  the  patient  seated  in  a  straight  chair  the  arms  are  placed 


96 


FRACTURES   AND   DISLOCATIONS 


ill  syiiinietrieal  positions  and  tlie  parts  carefully  inspected  before 
any  manipulation  is  attempted.  ^lucli  can  l)e  learned  l)y  insi)ectioii 
alone  and  if  this  source  of  information  is  fully  utilized  imicli  un- 
necessary manipulation  can,  as  a  rule,  be  avoided.  In  fractures  of 
the  clavicle  tiie  shoulder  is  usually  lowered  but  the  arm  itself  is 
not  shortened.  The  over-riding  deformity  so  common  in  fractures 
of  the  clavicle  is  usually  apparent.  .In  dislocations  of  the  shoulder 
the  change  in  humeral  axis,  flattening  of  the  shoulder  and  lowering 
of  the  axillary  fold  should  indicate  the  nature  of  the  injury  at  a 
glance.     The  attilude   in   dislocations  is  characteristic   in    lliat   the 


Fig.    129. — Measuring    humeral    length — from    acromion    to    externnl    epicondyle. 

Fig.   130. — Palpating  humeral  head  through  deltoid. 

Fig.    131. — Palpating   humeral   head   with   finder   tips   pressed   into    axilla. 

patient  seldom  makes  any  attempt  to  support  the  injured  member 
with  the  opposite  hand.  In  fractures  of  the  upper  end  of  the 
humerus  the  injured  arm  is  grasped  and  supported  with  the  greatest 
anxiety.  Both  active  and  passive  motion  are  restricted  in  disloca- 
tions while  abnormal  mobility  is  the  rule  in  fractures.  Ecchymosis 
is  common  about  the  shoulder  Avithin  twelve  to  twent3^-four  hours 
following  a  fracture,  but  in  luxations  it  is  almost  never  seen  except 
in  the  rare  subspinous  type.  Flattening  of  the  shoulder  is  some- 
times seen  in  fractures  of  the  anatomical  neck  but  it  is  never  as 
pronounced  as  in  dislocations  and  is  not  accompanied  by  change  in 
the  humeral  axis. 

The  head  of  the  humerus  should  be  palpated  through  the  deltoid 
and  again  through  the  axilla.  If  the  arm  is  carried  through  rota- 
tion while  the  head  is  palpated  the  surgeon  may  determine  to  his 
satisfaction  whether  or  not  the  head  follows  the  movements  of  the 
shaft.     The  shaft  of  the  humerus  should  be  measured  from  the  edge 


PRACTLIRES   OF    HIPPER   END    OF    irinvTERlIS  97 

of  the  acromion  to  the  external  epicondyle  and  compared  with  the 
opposite  side.  Shortening  usually  means  fracture,  while  length- 
ening is  indicative  of  the  more  common  types  of  dislocation  fsuh- 
coracoid  and  subglenoid).  The  coracoid  process  should  be  i)alpated 
where  it  approaches  the  surface  about  an  inch  below  the  junction 
of  the  middle  and  outer  thirds  of  the  clavicle.  The  clavicle, 
acromion  and  spine  of  the  scapula  should  be  palpated.  The  arm 
should  be  carried  through  the  normal  range  of  motion  and  restric- 
tion in  any  given  direction  and  increase  of  pain  should  be  noted. 

Fracture  of  the  neck  of  the  scapula  may  be  difficult  to  distinguish 
from  fracture  of  the  upper  end  of  the  humerus.  If  fracture  of  the 
upper  end  of  the  humerus  can  be  excluded  and  still  there  is  ab- 
normal mobility  of  the  upper  end  of  the  bone  with  crepitus,  the 
symptoms  are  indicative  of  fracture  of  the  glenoid  or  neck  of  the 
scapula.  It  may  be  possible  in  some  cases  to  palpate  the  margin 
of  the  displaced  glenoid  in  the  axilla. 

Differentiation  of  fractures  of  the  upper  end  of  the  humerus  from 
luxations  of  the  shoulder  and  fractures  and  dislocations  of  the 
clavicle  is  usually  not  difficult,  but  to  distinguish  between  the  differ- 
ent types  of  fracture  occurring  in  the  upper  end  of  this  bone  is 
often  not  an  easy  matter  without  the  aid  of  the  X-ray.  The 
symptoms  of  fracture  of  the  anatomical  neck,  surgical  neck, 
tuberosities  and  epiphyseal  separations  have  been  enumerated  and 
will  serve  in  making  a  differential  diagnosis  in  typical  cases  pending 
the  making  of  a  Rontgenogram. 

The  possibility  of  increasing  the  damage  to  the  soft  parts  should 
be  borne  in  mind  and  manipulation  should  be  as  gentle  and  brief 
as  possible.  Motion,  sensation  and  the  deep  reflexes  of  the  upper 
extremity  should  be  tested  to  recognize  complicating  injuries  to  the 
nerves  and  vessels.  The  condition  of  the  circumflex  may  be  ascer- 
tained by  tapping  the  deltoid  and  noting  the  contraction  of  its 
fibres. 

If  manipulation  is  especially  painful  or  the  swelling  pronounced, 
the  examination  is  best  conducted  under  anesthesia. 

Treatment. — Reduction  of  the  fragments  should  in  most  cases  be 
done  under  anesthesia.  A  careful  consideration  of  the  physical 
signs  and  symptoms  will,  as  a  rule,  afford  the  surgeon  sufficient 
information  concerning  the  fracture  to  correct  the  deformity. 
The  parts  should  then  be  immobilized  and  an  X-ray  taken  to  deter- 
mine the  position  of  the  fragments  and  the  details  of  the  fracture. 


98  FRACTURES   AND    DISLOCATIONS 

The  upper  end  of  the  sliaft  may  he  displaced  in  any  direction  and 
aecordingrly  the  maiiipidations  of  reduction  will  vary  in  ditt'erent 
cases.  The  usual  (Icfoi'inily,  however,  consists  in  an  upward  and 
inward  displacement  of  tlie  upper  end  of  the  lower  fragment.  Re- 
duction will  therefoi-e  usually  consist  in  forcing  the  upper  end  of 
the  shaft  outward,  while  traction  is  being  exerted  on  the  arm.  In 
making  outward  pressure  on  the  upper  end  of  the  shaft  the  surgeon 
should  avoid  exerting  the  pi-essure  directly  over  the  end  of  the  frag- 
ment, othei-wise  vessels  and  nerves  may  be  forced  against  the  sharp 
serrated  end  and  injured.  The  efifect  of  manipulation  can,  as  a 
rule,  be  recognized  by  pal|)ation  through  the  axilla.     With  the  frag- 


Fi?.    i;j2. — Shows    cig;ir-1»ox    bonrds    cut    to    proper    size   to   make    a    diagonal    axillary 
pad.      The  ends  to  the  right  have  been  hinged  together  with   adhesive  plaster. 

ments  in  good  position  there  should  be  a  disappearance  of  deformity. 
In  impacted  cases,  however,  and  in  those  accompanied  by  consid- 
erable crushing  of  cancellous  tissue,  a  certain  amount  of  shortening 
may  persist,  which  is  impossible  to  correct.  The  deformity  in  frac- 
tures of  the  upper  end  of  the  humerus  varies  greatly,  but  if  the 
surgeon  appreciates  the  relative  positions  of  the  fragments  and  the 
nature  of  the  break  he  w'ill  usually  be  able  to  effect  a  satisfactory 
reduction  by  means  of  extension,  counter-extension  and  manipula- 
tion. The  reduction  of  epiphyseal  separations  involves  the  same 
principles. 

With   reduction   accomplished    the   question    of   fixation    arises. 
The  methods  of  immobilization  are  similar  for  most  types  of  frac- 


FRACTURES   OP    TIPPER   END   OP    TTrTMERIIR 


99 


ture  of  the  upper  end  of  the  humerus.  The  most  common  method 
of  immobilization,  and  one  which  will  be  adapted  to  the  largest 
number  of  cases,  is  accomplished  by  means  of  the  axillary  pad  and 
the  moulded  plaster  shoulder  cap.     Various  methods  of  preparing 


Fig.    133. — Shows    axillary    pad   completed.      Cotton    has   been    packed    in    between    the 
boai'ds  and  a  layer  of  cotton  used  to  cover  the  surface.      The  whole  is  then  bandaged. 

and  applying  these  two  elements  in  the  dressing  have  been  described 
and  there  is  little  to  be  said  of  any  of  them  as  long  as  they  accom- 
plish the  desired  result,  which  is  fixation  of  the  fragments  in  proper 
position  without  undue  constriction  of  the  arm  or  irritation  of  the 


Fig.   134. 


Fig.   135. 


Fig.    136. 


Pig.    134. — View    of    axillary    pad    from    behind.      Note    how    the    pad    supports    the 
humerus  down  to  the  internal  epicondyle. 
Pig.   135. — Same  seen  from  the  front. 
Pig.   136. — Same  with  arm  raised.     Note  the  oblique  lower  end  of  pad. 

skin.  The  details  of  the  most  satisfactory  methods  will  be  described. 
The  key-note  to  the  proper  immobilization  of  the  shoulder  is  the 
axillary  pad. 

The  axillary  pad  should  support  as  much  of  the  humerus  as  pos- 


100  FRACTURES   AND   DISLOCATIONS 

sible  without  interfering;  with  the  upper  part  of  tlie  forearm  which 
is  maintained  in  a  position  of  semitlexion.  A  very  satisfaetoi-y  pad 
is  made  in  the  following  maiuuT:  take  two  |)ieces  of  cigar-box  (the 
lid  and  bottom)  and  cut  them  so  that  tliey  will  be  a  little  broader 
than  the  arm  and  tlien  hinge  two  of  the  ends  together  inside  and 
out  with  adhesive  as  shown  in  Fig.  ]'.V2.  Tlie  Ijoai'ds  are  then  placed 
in  the  ojiposite  axilla  (hinged  ends  ui))  for  the  puri)0sc  of  measuring 
and  marking  tlie  j)roper  length.  The  pad  when  comi)leted  should 
come  to  about  the  level  of  the  internal  ei)icondyle  posteriorly,  l)ut 
should  be  short  enough  anterioi-l}^  to  clear  the  top  of  the  semi- 
flexed forearm.  To  aecom])lish  this  it  will  be  found  necessary  to 
cut  the  lower  ends  of  the  boards  diagonally  (as  shown  in  Fig.  132). 
With  the  boards  cut  to  the  proper  size  (due  allowance  being  made 
for  the  padding)  the  angle  is  stutfed  with  cotton  till  a  wedge  of  the 
proper  thickness  is  obtained.  The  outside  of  the  pad  is  then  cov- 
ered with  cotton  and  finished  by  securing  the  padding  in  position 
with  a  roller  bandage.  The  tendency  for  those  not  accustomed  to 
constructing  this  dressing  is  to  make  the  pad  too  long,  and  when 
this  is  done  the  antero-inferior  angle  will  nmke  the  patient  miserable 
by  pressing  into  the  upper  part  of  the  forearm,  or  else  the  pad  will 
tend  to  slip  backward  and  fail  to  properly  support  the  humerus. 
The  outer  side  of  the  pad  should  be  evenly  covered  so  that  it  will 
present  a  flat  plane  for  the  humerus  to  rest  on.  The  pad  is  secured 
in  position  by  three  pieces  of  adhesive  as  shown  in  Figs.  135  and 
136.  Two  of  them  pass  over  the  opposite  shoulder  while  the  third 
encircles  the  body.  The  surgeon  should  see  to  it  that  the  pad  is 
properly  fitted  and  placed  before  he  proceeds  with  the  making  of 
the  shoulder  cap.  Heavy  card  board  (book-binders  board)  may  be 
used  in  jjlace  of  the  wood,  but  if  the  material  is  too  light  the 
sides  will  tend  to  bow  when  the  angle  is  stuffed  with  cotton,  as 
described  above.  When  this  occurs  the  side  of  the  pad  does  not 
present  the  necessarj'^  flat  surface  for  the  humerus  to  rest  against. 
Light  card  board  is  entirely  inadequate,  and  stuffing  of  the  space 
between  the  body  and  trunk  with  folded  towels  is  mentioned  simply 
to  be  condemned.  I\Iany  different  methods  of  making  an  axillary 
pad  may  be  followed  but  the  above  will  be  found  as  satisfactory 
as  any. 

The  plaster  shoulder  cap  is  shown  in  Fig.  137  and  is  applied  as 
follows:  After  reduction  has  been  effected  and  the  axillary  pad 
placed  in  position,  a  i)attern  is  cut  out  of  sheet-cotton  to  properly 


FRACTURES   OF    TIPPER   END   OF    HUMERUS 


101 


embrace  the  arm  and  shoulder.  It  is  best  to  lay  the  cotton  on  the 
shoulder  and  cut  the  pattern  in  this  position.  Ten  or  twelve  layers 
of  crinolin  (or  half  again  as  many  layers  of  gauze)   are  then  cut 


■ 

1 

H 

■ 

^^^^^^^Bi '  j^^^^k 

^ 

^^H 

\ "  ■. 

^B 

1^     1 

1    1 

li 

L. 

\^A 

m 

^1 

Fig.    137. — Plaster   shoulder    caiJ   in   position.      i>Iote   tlie   encircling   strap   of   adhesive 
plaster. 

according  to  the  pattern,  immersed  in  plaster  cream,  wrung  out  and 
applied  to  the  shoulder.  The  sheet-cotton  pattern  is  applied  to  the 
shoulder  first  and  acts  as  the  lining  for  the  shoulder  cap.     The 

I 


Fig.    138. 


Fig.    139. 


Fig.    140. 


Fig.    138. — Axillary   pad   in   position   and   arm  bandaged. 

Fig.   139. — Plaster   shoulder   cap   in  position. 

Fig.    140. — Swathe    encircling    body     and    taking    place    of    sling. 

shoulder  cap  should  be  secured  to  the  body  as  quickly  as  possible 
with  a  wide  roller  bandage  and  the  patient  kept  perfectly  quiet 
until  the   plaster  has   thoroughly   set   and   dried.     Later   on   the 


102 


FRACTITRES   AND    DISLOCATIONS 


bandages  may  be  removed  and  the  cap  secured  in  position  by  means 
of  a  body  swatlie  or  strips  of  adhesive  plaster.  Another  method  of 
securing  the  arm  and  splint  to  the  body  is  by  encircling  both  with  a 
sufficient  nuhiber  of  turns  of  plaster  bandage.  Wet  crinolin 
bandage  may  be  used  instead.     When  this  is  done  the  trunk  should 


Fis.    1-)1. 


143. 


Fig.    141. — Middeldorf  triangle. 

Fig.  142. — The  Monks  triangle.  A.  shows  the  wire  bent  to  proper  form.  B.  shows 
same  padded  and  bandaged. 

Fig.  143. — Osgood-Penhallow  splint  for  treatment  of  fractures  of  the  upper  end  of 
the   humerus   in   abduction. 

be  protected  with  sheet  cotton  to  prevent  subsequent  irritation  of 
the  skin.  The  cap  should  cover  the  shoulder  on  all  sides,  and  if 
additional  security  is  desired  it  may  be  made  to  extend  well  onto 
the  chest  both  in  front  and  behind.  In  fractures  of  the  upper  end 
of  the  humerus  it  will  seldom  be  necessary  to  include  the  elbow  or 
forearm  in  the  splint. 


FRACTURES   OP    UPPER   END   OF    HUMERUS  lOo 

It  is  well  to  snugly  bandage  the  arm,  forearm  and  hand  with  a 
flannel  bandage  before  the  pad  and  shoulder  cap  are  ap[)lied. 

A  method  offering  very  solid  fixation  is  a  phister  spica  of  the 
arm  and  chest  though  it  does  not  permit  of  frequent  removal  or  easy 
adjustment  during  the  after-treatment.  When  the  spica  is  em- 
ployed the  arm  and  chest  should  be  well  covered  with  sheet  cotton, 
and  after  the  dressing  is  finished  an  axillary  pad  should  be  placed 
in  position  to  support  the  arm. 

The  cravat  sling  is  called  for  with  any  of  tlie  plaster  dressings 
about  the  shoulder  except  when  the  forearm  is  included  in  the 
splint. 

It  is  advisable  in  most  cases  of  fracture  of  the  upper  end  of  the 
humerus  to  employ  an  anesthetic  during  examination  and  reduc- 
tion though  it  is  more  satisfactory  to  apply  a  plaster  dressing  when 
the  patient  is  conscious  and  able  to  assume  a  convenient  position. 
When  the  causative  trauma  is  great  and  the  ensuing  traumatic 
reaction  pronounced  it  is  often  better  to  treat  the  patient  in  bed 
during  the  first  few  days  and  to  delay  the  application  of  a  perma- 
nent dressing.  During  this  time  the  arm  may  be  secured  on  an 
axillary  pad  and  sand  bags  applied  to  the  outer  side  of  the  arm  to 
steady  the  parts.  The  local  and  intermittent  use  of  the  ice  cap 
will  be  of  service  in  controlling  the  inflammatory  reaction.  In  some 
instances  the  patient  will  be  more  comfortable  with  the  arm  resting 
on  a  pillow.  If  the  suffering  is  great,  morphine  should  be  ex- 
hibited. 

Occasionally  cases  are  seen  in  which  reduction  cannot  be  main- 
tained with  the  arm  in  a  position  such  as  assumed  when  the 
axillary  pad  and  plaster  shoulder  cap  are  employed.  Abduction, 
outward  rotation  or  a  forward  displacement  of  the  upper  fragment 
may  require  a  corresponding  position  of  the  lower  fragment  to  keep 
the  fractured  surfaces  in  apposition  and  the  fragments  in  align- 
ment. To  meet  the  requirements  in  such  cases  a  number  of  splints 
have  been  devised.  The  Middledorf  triangle  maintains  the  arm 
in  a  position  of  partial  abduction  and  inward  rotation  and  is  effec- 
tive in  some  cases  in  preventing  recurrence  of  deformity.  (See 
Fig.  141.)  The  Monks  triangle  holds  the  arm  in  a  nearly  horizontal 
position  with  the  elbow  carried  forward.     (See  Fig.  142.) 

By  means  of  a  plaster  cast  of  the  upper  extremity  and  trunk 
the  arm  may  be  fixed  in  almost  any  position  desired.  Taking  every- 
thing into  consideration  it  is  probably  the  most  satisfactory  form 


104 


FRACTURES   AND    DISLOCATIONS 


ol"  iimiiubili/alioii  in  instaiie-i's  in  wliicli  tlic  arm  may  not  be  treated 
at  tlie  sitle   Ijceause  oi*  displaeement   of   llie   iippei-   fi-agmeut. 

AVheu  uncomfortable  and  awkward  positions,  sueli  as  maintained 
by  the  above  -splints,  are  necessary  to  keep  the  fragments  in  proper 
relation,  the  question  of  operation  should  be  considered.  It  is  the 
author's  opinion  that  most  cases  of  this  kind  (in  which  reduction 
cannot  be  nuiintained  with  the  arm  by  the  side)  should  be  operated 
upon,  and  the  fragments  secured  in  position  by  direct  fixation. 


Fig.  144. — Plaster  cast  for  treatment  of  fracture  of  the  upper  end  of  the  li-.in  ir  -.s 
in  abduction.  In  applying  the  cast  the  humerus  may  be  fixed  in  almost  any  yj^^ii'dn 
desired. 

Fig.  145. — Plaster  cast  for  treatment  of  fractures  of  the  upper  end  of  the  humerus 
in  abduction.  This  cast  fixes  the  humerus  in  a  position  of  greater  outward  rot.i- 
tion. 


Operative  Treatment. — The  oases  of  fracture  of  the  upper  end 
of  the  humerus  in  which  operation  is  indicated  are  nvimerous  but 
the  proper  selection  of  these  eases  requires  the  most  seasoned  surgi- 
cal judgment.  Fractures  in  which  the  displacement  is  pronounced 
and  not  reducible  by  ordinary  methods  should  be  operated.  Recur- 
rence of  deformity  during  the  after-treatment  is  ordinarily  an  indi- 
cation for  operative  intervention.  Cases  in  which  the  upper  frag- 
ment is  abducted,  rotated,  or  displaced  forward  may  be  treated 
by  some  form  of  dressing  which  immobilizes  the  arm  in  a  position 
corresponding  to  the  deformity  of  the  upper  fragment.  Such  dress- 
ings, however,  are  more  or  less  uncomfortable  and  insecure  and  in 
most  instances  it  wall  be  advisable  to  expose  the  fragments,  wdre  or 
plate  them  together  and  then  fix  the  arm  by  the  side  with  the 
ordinary  axillary  pad  and  shoulder  cap  dressing. 


FRACTURES   OP    UPPER   END    OP    HUMERUS  105 

The  fragments  are  to  l)e  exposed  through  a  vertical  incision  on 
the  anterior  or  external  aspect  of  the  slioulder.  The  ('irciunflcx 
nerve  will  he  found  winding  around  the  surgical  neck  of  the  bone 
and  should  be  avoided.  It  is  best  to  expose  the  fragments  by  dull 
dissection  in  the  deeper  part  of  the  wound  until  the  nerve  has  been 
located  and  isolated.  With  the  fragments  exposed  the  needs  of  the 
case  are  determined  and  the  details  of  the  operation  from  this  time 
on  will  vary  accordingly.  Reduction  of  deformity  is  performed  by 
means  of  extension,  counter-extension  and  manipulation,  and  is 
rendered  easier  by  direct  manipulation  of  the  fragments  when 
necessary.  The  fact  that  the  fragments  may  be  directly  inspected 
during  manipulation  is  of  the  greatest  service  in  correcting  the 
displacement.  If  a  firm  engagement  between  the  fragments  can  be 
obtained  by  manipulation  the  wound  may  be  closed  and  the  opera- 
tion concluded;  if,  however,  there  is  a  tendency  to  redisplacement 
some  form  of  internal  fixation  must  be  employed.  A  consideration 
of  the  illustration  on  page  83  will  show  that  the  structure  of  the 
bone  above  the  surgical  neck  is  composed  of  a  wide-meshed  cancel- 
lous tissue  covered  only  by  a  very  thin  layer  of  compact  bone,  and  it 
is  in  this  formation  that  very  little  dependence  can  be  placed  on 
nails,  pegs,  screws,  etc.  Silver  wire  will  afford  the  most  trust- 
worthy fixation  and  should  be  given  the  preference  in  the  region  of 
the  anatomical  neck.  It  is  frequently  the  case  that  a  simple  loop 
of  wire  passing  through  the  outer  side  of  the  fracture  as  shown  in 
Fig.  98  will  secure  a  safe  and  accurate  apposition.  The  Lane 
plate  has  been  used  in  the  region  of  the  greater  tuberosity  though 
it  is  not  reasonable  to  expect  security  from  it  when  the  screws 
holding  it  are  not  placed  in  a  fairly  heavy  layer  of  compact  tissue. 
Accordingly  it  is  of  greater  value  a  little  lower  in  the  bone.  It  is 
sometimes  necessary  to  excise  the  head  of  the  bone  because  of 
extensive  comminution,  or  in  old  eases  because  of  non-union.  It  is 
well  to  remember  that  the  head  very  rarely  suffers  necrosis  follow- 
ing separation  from  the  shaft.  Attempts  to  save  the  head  are 
usually  successful  with  accurate  apposition  and  the  proper  degree 
of  fixation.  Reduction  and  fixation  of  fractures  of  the  surgical 
neck  are  not  as  a  rule  attended  by  great  difficulty  unless  there  is 
extensive  comminution  of  the  upper  fragment.  When  the  upper 
fragment  is  broken  into  many  pieces  it  may  be  impossible  to  com- 
pletely restore  the  bone  to  its  original  lines.  A  wire  encircling  the 
surgical  neck,  with  notches  in  the  bone  to  prevent  its  slipping  down- 


106  FRACTURES   AND   DISLOCATIONS 

wai-d.  may  be  of  great  value  in  lonofitudinal  splitting.  It  should 
be  so  placed  as  not  to  iiilcrfd'c  with  the  long  head  of  the  biceps. 
Isolated  fractures  ul'  llie  tuberosities  are  rare  injuries.  Little 
difficulty  should  be  experienced  in  returning  the  detaelied  tuberosity 
to  its  original  position  and  securing  it  in  place. 

In  epii)hy.seal  separations  reduction  of  the  deformity  will  usually 
be  all  that  is  required,  as  displacement  is  prevented  by  the  projec- 
tion of  the  center  of  tbe  diaphysis  upward  into  the  epiphysis. 
(See  Figs.  110  and  111.)  Suture  of  the  periosteum  on  the  outer 
side  of  the  bone  will  iuci-ease  the  security  of  reduction.  If  a  tend- 
enc}''  to  recurrenee  of  deformity  is  present  absorbable  suture 
material  may  be  passed  through  drill  holes  in  the  bone.  Non- 
absorbable suture  material  should  not  be  used  across  an  epiphyseal 
cartilage. 

It  is  well  to  insert  a  small  drain  of  silkworm  gut  before  the  wound 
is  closed  to  relieve  the  joint  of  blood  and  serum ;  this  drain  should 
be  removed  in  from  twenty-four  to  forty-eight  hours. 

After-Treatment. — In  the  average  child  or  young  adult  union 
may  be  expected  at  the  end  of  four  weeks,  while  a  middle-aged 
person  should  be  allowed  from  live  to  six  weeks  for  callous  forma- 
tion. In  the  aged  union  may  be  much  delayed.  The  acute  swelling 
about  the  joint  will  usually  have  subsided  at  the  end  of  ten  days  or 
two  weeks.  During  the  time  the  shoulder  is  decreasing  in  size  the 
padding  on  the  inside  of  the  shoulder  cap  will  require  frequent 
changing  and  adjustment  so  that  the  cap  may  properly  fit  the 
shoulder.  If  the  swelling  has  been  great  it  may  be  nece.ssary  to 
apply  a  new  cap  when  the  shoulder  approaches  the  normal  in  size. 

The  ease  should  be  seen  daily  for  the  first  ten  days,  after  which 
every  two  or  three  days  will  be  sufficient.  The  axillary  pad  some- 
times becomes  loosened  and  is  likely  to  slip  downward  or  back- 
ward, and  if  not  replaced  may  be  responsible  for  a  change  in  the 
position  of  the  fragments.  Gentle  passive  motion  should  be  begun 
at  the  end  of  two  or  two  and  a  half  weeks  in  uncomplicated  cases. 
Passive  motion  should  at  all  times  be  gentle,  and  the  production 
of  pain  must  represent  the  limit  of  motion.  The  splints  should 
be  removed  at  the  end  of  four  to  six  weeks,  according  to  the  age 
and  condition  of  the  patient,  and  the  arm  carried  in  a  sling  for 
another  ten  daj^s.  The  patient  should  be  especially  cautioned  not 
to  submit  the  arm  to  any  great  strain  for  the  first  two  months  fol- 
lowing the  removal  of  splints.     Extreme  abduction  is  the  last  mo- 


FRACTURES   OF    UFPER   END   OF    HUMERUS  107 

tion  to  be  regained  by  the  patient  and  in  elderly  persons  it  is  not 
infrequently  lost  permanently.  Should  paralysis  of  any  of  the 
nerves  supervene  during  the  after-treatment  (as  evidenced  by 
wrist  drop  or  contractures)  we  should  lose  no  time  in  exploring  the 
nerve  involved  where  it  crosses  the  line  of  fracture.  The  circum- 
flex is  the  single  nerve  most  frequently  involved  in  fractures  of  the 
upper  end  of  the  humerus.  End  results  following  operations  on 
the  nerves  cannot  be  expected  inside  of  four  to  six  months  at  the 
earliest.  Atrophy  of  the  deltoid  not  infrequently  occurs  from 
disuse  alone  without  injury  to  the  circumflex.  This  condition  is 
not  in  itself  a  cause  for  anxiety  since  the  muscle  will  regain  its  size 
and  tone  with  use. 

Following  reduction  of  an  epiphyseal  separation  fixation  should 
be  maintained  for  three  or  four  weeks. 

Early  passive  motion  is  of  the  greatest  value  in  fractures  of  the 
upper  end  of  the  humerus.  Restricted  motion  in  the  shoulder  is 
often  the  result  of  a  too  prolonged  immobilization.  If  joint  ad- 
hesions are  present  after  union  is  firm  they  may  be  forcibly  broken 
up  under  anesthesia,  but  before  this  is  attempted  the  surgeon  should 
be  positive  that  the  callus  is  firm  enough  to  stand  the  manipulation 
Mdthout  refraeture. 

Prognosis. — The  outlook  in  fractures  of  the  upper  end  of  the 
humerus  will  depend  on  the  severity  of  the  break  and  the  age  and 
condition  of  the  patient.  A  fair  degree  of  reduction  will  usually 
be  followed  by  perfect  recovery  in  youthful  subjects.  The  older  the 
patient  the  greater  the  probability  of  incomplete  restoration  of 
function.  In  the  aged  non-union  may  follow  in  spite  of  the  most 
perfect  treatment.  In  patients  past  middle  life  there  is  often 
slight  restriction  of  motion  and  pain  about  the  joint  occurring  with 
changes  in  the  weather.  The  range  of  motion  may  be  free  and  yet 
the  shoulder  weak. 

Loss  of  growth  following  epiphyseal  separation  is  an  extremely 
rare  condition  and  need  not  be  expected  if  anything  like  a  fair 
reduction  has  been  accomplished  following  the  accident.  Moderate 
deformity,  if  present,  will  decrease  as  the  years  go  by. 


CHAPTER  VIII. 

FRACTURES  OF  THE  SHAFT  OF  THE  HUMERUS. 

Surgical  Anatomy. — To  appreciate  the  deformities  aeconipanying 
fraetures  of  tlie  sliaft  of  the  humerus  the  attachments  and  directions 
of  pull  of  the  tlifferent  muscles  should  be  known.  (See  Figs.  146 
and  147.)  AViien  the  line  of  fracture  is  through  the  insertions  of 
the  peetoralis  major,  latissimus  dorsi  and  teres  major  the  deformity 
is  usually  slight  and  consists  of  an  inward  displacement  of  both 
fragments  so  that  the  deformity  is,  as  a  rule,  purely  angular. 
"When  the  fracture  is  below  the  insertions  of  these  muscles,  but  above 
the  deltoid  eminence,  the  lower  fragment  will  usually  be  displaced 
upward  and  outward  by  the  deltoid,  while  the  upper  fragment  is 
drawn  inward  by  the  pull  of  the  peetoralis,  teres,  and  latissimus. 
AYhen  the  fracture  is  below  the  insertion  of  the  deltoid  the  u])per 
fragment  will  be  displaced  outward.  In  any  fracture  of  the 
humeral  shaft  the  serrated  ends  may  be  firmly  enough  engaged  to 
prevent  lateral  and  overriding  displacement,  and  under  such  cir- 
cumstances the  deformity  is  purely  angular  if  present  at  all. 
Shortening  of  the  arm  is  caused  for  the  most  part  by  the  action  of 
the  biceps  and  triceps. 

The  humerus  has  a  wider  range  of  motion  than  any  other  bone 
in  the  body  and  the  varieties  of  strain  to  which  it  may  be  subjected 
are  great.  Accordingly  we  may  see  any  type  of  fracture  common 
to  long  bones.  The  shaft  of  the  humerus  is  composed  of  a  heavy 
tube  of  compact  tissue  which  grows  larger  in  circumference  and 
lighter  in  structure  as  the  extremities  are  approached. 

The  musculo-spiral  nerve  supplying  the  extensors  and  supinators 

descends  obliquely,  from  above,  downward  and  outward,  between 

the  two  humeral  heads  of  the  triceps.     It  lies  in  contact  with  the 

bone  in  the  musculo-spiral  groove  and  in  this  position  is  particu- 

lai-ly  exposed  to  injury  in  fractures  of  the  humeral  shaft.     It  may 

be  injured  by  direct  contusion  and  laceration  at  the  time  of  the 

accident  or  it  may  be  subsequently  caught  and  compressed  by  the 

callus. 

108 


FRACTURES   OP    SHAFT    OK    TTTJMRRKS 


109 


r.MiN. 


ECU  -^ 


"^  Tro. 

—  c. 

~—E.K- 


Fig.    146. 


Fig.    147. 


Figs.  146  ard  147. — ^Views  of  the  anterior  and  posterior  surfaces  of  the  riglit 
humerus.     The  arrows  indicate  the  pull  of  the  attached  muscles. 

S.,  Head  of  the  humerus;  A.N.,  Anatomical  neck;  S.N.,  Surgical  neck;  L.D..  At- 
tachment of  the  latissimus  dorsi ;  T.M.,  Attachment  of  the  teres  major;  Cb.,  Coraco- 
brachialis;  T'.,  Outer  head  of  the  triceps;  T".,  Inner  head  of  the  triceps;  M.S.,  Musculo- 
spiral  groove;  B.,  Bicipital  groove;  P.M..  Insertion  of  the  pectoralis  major;  /..  Infra- 
spinatus; T.Min.,  Teres  minor;  D.,  Insertion  of  the  deltoid;  S.L.,  Supinator  longus; 
E.O.R.L.,  Extensor  carpi  radialis  longior ;  17.,  Groove  for  ulnar  nerve;  P.R.,  Pronator 
radii  teres;  F.F.,  Flexors  of  the  forearm;  F.G.TJ.,  Flexor  carpi  ulnaris ;  Iro.,  Trochlear 
surface  of  humerus;   C,  Capitellum;   E.F.,  Extensors  of  the  forearm. 


110 


FRACTCRES    AND    DISLOCATIONS 


Inward  displacement  of  one  or  both  of  the  fragments  may  be  the 
cause  of  laceration  or  compression  of  the  brachial  artery  which  lies 
to  the  inner  side  of  the  shaft. 

Green-stick  fractures  are  seldom  seen  and  multiple  breaks  are 
uncommon.  Direct  violence  is  usually  responsible  for  fractures  of 
the  transverse  type ;  spiral  and  oblique  fractures  are  the  result  of 
twisting  strains.     IMusculai-  action  is  especially  productive  of  frac- 


Fig.    148. 


Fig.    149. 


Fig.    148. — Spiral,   comminuted   fractiire  of   luimcral  shaft. 

Fig.    149. — Fracture  of  shaft  witli  overriding  and  rotary  deformity. 

ture  of  the  humeral  shaft,  and  in  some  cases  (particularly  in  elderly 
persons)  the  degree  of  causative  trauma  may  be  disproportionately 
small.     Impaction  of  the  fragments  is  almost  never  seen. 

The  most  common  seat  of  fracture  is  at  or  a  little  below  the 
middle  of  the  shaft. 

Symptoms.^ — There  is  pain,  lo.ss  of  function,  crepitus,  abnormal 
mobility  and  varying  deformity.  Swelling  usually  develops  rapidly 
and  ecchymosis  is  seen  within  the  first  day.  The  relative  position 
of  the  fragments  varies  with  the  level  of  the  break  and  has  been 


PRACTIJRKS    OF    SHAFT    OF    JIUMERUS  111 

explained  under  "Snrsicul  Anatomy,"  page  108.  The  deformity 
is  almost  always  sufficiently  pronounced  to  be  recognized  by  inspec- 
tion alone. 

The  patient  supports  the  injured  member  with  the  opposite 
hand  in  a  manner  which  is  characteristic,  (See  Diagnosis  under 
"Dislocations  of  the  Shoulder,"  page  65.) 

The  patient  is  able  to  move  the  hand  and  fingers,  and  the  reflexes 
below  the  site  of  the  fracture  are  intact  unless  some  of  the  nerves 
have  been  injured. 


Fig.    150 


Fig.    150. — Multiple   spiral   fracture   of   humeral    shaft   with   pronounced   deformity. 
Fig.  151. — Oblique  fracture  of  humeral  shaft  with  separation  of  fragments.      (Taken 
through  heavy  fibre  splint.) 

A  weakening  or  absence  of  the  radial  pulse  indicates  laceration 
or  compression  of  the  brachial  artery.^ 

The  development  of  a  hematoma  may  sometimes  be  recognized 
in  the  arm  following  tearing  of  the  artery. 

Diagnosis. — Fractures  of  the  humeral  shaft  are,  as  a  rule, 
recognized  without  difficulty.  The  deformity  is  usually  so  pro- 
nounced that  the  diagnosis  can  be  made  by  inspection  alone.  As 
soon  as  the  arm  is  manipulated  the  point  of  abnormal  mobility 
is  apparent  in  almost  all  cases.  Fracture  of  the  shaft  is  a  common 
fracture  and  is  not  infrequently  associated  with  injuries  to  neigh- 


1 A    thrombosis    of   the   brachial    artery    may    be    slow    in    forming    and    when    it    is    the 
alteration  in  the  pulse  will  be  delayed. 


112 


FRACTURES    AND    DISLOCATIONS 


boring  bones  or  joints.     The  surgeon  should  therefore  be  system- 
atic in  his  examination  and  determine  tlie  eonditinns  of  llu^  clavicle, 


i 


Fisr.  152. — Oblique  fracture  of  humerus  a  little  below  its  middle  with  nvciinliu;;  aut 
angular  displacement  of  the  fragments.  Upper  fragment  anterior  and  e.^ternal  to  lower 
fragment.  Line  of  fracture  passes  bflow  in-ertion  of  deltoid,  hence  the  outward  dis- 
placement of  upper  fragment,  while  the  biceps  and  triceps  cause  the  fragments  to  over- 
ride. Tn  this  t'pe  of  fracture  complete  reduction  is  often  impossible  without  operative 
intervention,      rhotosrrarh    t;ikpn    within    an    haur    of    the    accident. 


Fig.  153. — Crushing  injury  of  arm.  This  case  was  struck  by  a  falling  wall,  the 
humerus  fractured  and  the  upper  portion  of  arm  forced  through  rent  in  skin.  Skin 
and  fascia  only  tissues  connecting  upper  and  lower  portions  of  arm.  Arrow  points  to 
lower  end  of  upper  fragment  directly  above  which  may  be  seen  tip  of  hemostat  holding 
end  of  brachial  artery.  Amputation.  Recovery.  Photograph  tjiken  while  patient  is 
under   anesthetic   and   just   prior   to   operation. 

scapula,  elbow,  ribs,  etc.,  before  the  diagnosis  can  be  considered 
complete.  An  X-ray  plate  should  be  made  to  afford  further 
information  concerning  the  nature  of  the  fracture. 


FRACTURES   OF    SHAFT   OF    HUMERUS  113 

Treatment. — The  treatmt^nt  will  vary  according  to  the  location 
of  the  fracture  and  the  direction  and  degree  of  displacement.  It 
is  best  in  most  instances  to  reduce  the  deformity  under  anesthesia. 
Traction,  counter-traction  and  manipulation  will  suffice  in 
many  cases  to  bring  the  fragments  into  proper  apposition  and 
alignment.  In  transverse  fractures  with  overriding  (especially 
when  the  ends  are  deeply  serrated),  reduction  can  best  be  effected 
by  producing  angular  deformity  and  manipulating  the  fragments 
in  this  position  until  the  serrated  ends  have  been  engaged.  The 
bone  is  then  straightened  and  appropriate  dressings  applied.  In 
producing  angular  deformity  for  the  purpose  of  engaging  the  ends, 
the  arm  should  be  bowed  outward,  to  avoid  stretching  of  the  artery 
and  nerves  which  lie  on  the  inner  side  of  the  shaft.  It  is  usually 
not  difficult  to  effect  reduction  of  a  spiral  or  oblique  fracture  but  it 
is  frequently  impossible  to  prevent  recurrence  of  deformity  in 
breaks  of  these  types  without  resorting  to  internal  fixation.  Out- 
ward rotation  of  the  upper  fragment  in  a  spiral  or  oblique  fracture 
may  act  as  a  serious  obstacle  to  reduction. 

Fractures  of  the  upper  third  of  the  shaft  are  to  be  treated  with 
dressings  such  as  already  described  in  the  Treatment  of  "Fractures 
of  the  Upper  End  of  the  Humerus"  (page  101),  namely  axillary 
pad,  plaster  shoulder  cap,  cravat  sling,  body  swathe,  etc.  There 
is  this  to  be  said,  however,  in  regard  to  the  shoulder  cap ;  the  lower 
the  fracture  the  greater  the  need  of  extending  this  dressing  down- 
ward to  include  the  forearm.  Coaptation  splints  are  often  used  in 
fractures  of  the  middle  of  the  shaft  though  they  may  well  be  dis- 
pensed with,  as  a  permanent  dressing,  in  favor  of  a  properly  applied 
shoulder  cap.  It  is  a  common  practice  to  treat  the  condition  during 
the  onset  and  subsidence  of  swelling  with  the  axillary  pad,  coapta- 
tion splints,  body  swathe  and  sling.  Later  on  the  coaptation  splints 
are  replaced  by  the  plaster  shoulder  cap  as  a  permanent  dressing. 
In  fractures  of  the  lower  third  the  elbow  should  be  solidly  immobil- 
ized. The  axillary  pad  is  not  appropriate,  and  carrying  the  arm 
in  a  sling  is  entirely  inadequate  to  secure  fixation  if  the  fracture  is 
near  the  elbow.  A  most  satisfactory  method  of  fixation  in  this 
portion  of  the  shaft  is  that  shown  in  Fig.  215  and  is  described  below. 

The  following  may  be  considered  a  fair  example  of  the  treatment 
of  a  fracture  of  the  shaft  of  the  humerus  shortly  following  the  acci- 
dent. The  patient  is  placed  in  as  comfortable  a  position  as  possible, 
preferably  the  recumbent,  and  an  examination  made  of  the  parts, 


114 


KRA("TUR1':S    AND    DISLOt'ATlONS 


to  detenniiu'  as  accurately  as  may  bo  the  exact  nature  and  position 
of  the  fracture.  Tlie  examination  is  more  satisfactorily  carried  out 
under  anesthesia.  It  should  be  remembered  that  the  less  the  parts 
are  manipulated  the  better  it  will  be  for  the  soft  tissues  surrounding 
the  jagged  eiuls  of  the  fragments.  After  the  fracture  has  been 
diagnosed  the  proper  dressings  should  be  prepared  so  that  every- 
tliiner  mav  be  in  readiness  as  soon  as  reduction  has  been  effected. 


Strouie\  er    riishion. 


It  is  needless  to  add  that  the  surgeon  should,  at  this  time,  satisfy 
himself  as  to  -which  form  of  dressing  will  best  meet  the  requirements 
of  the  case  in  liaiid.  In  instances  in  which  the  trauma  has  been 
great  it  is  often  best  to  leave  the  parts  undisturbed  and  to  treat 
the  patient  in  the  reeundDent  position  for  a  week  or  ten  days  until 
the  acute  inflammatorv  reaction  has  sul)sided.     During  this  time 


Fig.   155. — .\rm  biiiuUiKed  and  axillary  i>ad  in   position. 
Fig.    15G. — Coaptation    splints   applied. 
Fig.    157. — Swathe   encircling  body   and   acting   as   sling. 
elusive. ) 


Pig.    157. 


(See   Pigs.    132   to   142 


the  arm  may  be  supported  on  a  pillow  and  the  ice  cap  used  to 
control  the  reaction.  The  Stromeyer  cushion,  or  one  of  its  modifi- 
cations, may  be  used  to  advantage.  If,  on  the  other  hand,  it  seems 
advisable  to  immobilize  the  arm  at  once  the  following  details  may 
be  observed.  The  arm  and  side  of  the  chest  are  sponged,  dried  and 
dusted  with  talcum  powder,  special  attention  being  paid  to  the 
axilla.     An  axillary  pad  is  then  constructed  as  described  on  page 


FRACTURES   OF    SHAFT   OF    HUMERUS  115 

100.  Coaptation  splints  arc  next  made,  by  placing  thin  wood  on 
adhesive  plaster  (cigar-box  wood  is  excellent)  and  splitting  llie 
wood  with  a  knife.  The  splint  should  include  as  mucli  of  tli(!  arm, 
from  the  shoulder  to  the  elbow,  as  possible  without  pressing  into  the 
axillary  fold  above,  or  the  top  of  the  flexed  forearm  below.  'Vhv. 
portion  of  the  coaptation  splint  on  the  outer  side  of  the  arm  may 
be  longer  than  that  on  the  inner  side.  A  body  swathe  is  next  pre- 
pared of  two  or  three  thicknesses  of  heavy  muslin.  It  should  be 
long  enough  to  encircle  the  body  and  injured  member  and  broad 
enough  to  extend  from  the  top  of  the  shoulder  to  a  point  below  the 
elbow.  A  cravat  sling  is  then  prepared  and  the  necessary  materials 
are  ready. 

The  axillary  pad  is  placed  in  position  and  secured  with  adhesive 
plaster,  after  which  the  surgeon  is  ready  to  attempt  reduction. 
The  injured  member  is  grasped  above  and  below  the  seat  of  frac- 
ture, and  the  fragments  gently  but  firuily  manipulated  until  the 
senses  of  sight  and  touch  pronounce  the  joosition  satisfactory.  The 
coaptation  splint  is  then  well  padded,  applied  and  secured  in 
position  with  adhesive  plaster.  The  arm  is  then  firmly  placed 
against  the  axillary  pad  and  secured  by  the  body  swathe.  The 
cravat  sling  completes  the  dressing,  or  in  lieu  of  the  sling  the  fore- 
arm may  be  included  in  the  swathe,  allowing  the  hand  to  emerge 
between  the  layers  where  they  are  pinned  together.  This  form  of 
dressing  is  least  likely  to  strangulate  the  arm  during  the  first  week 
of  treatment  when  the  traumatic  reaction  and  swelling  are  in 
progress. 

A  very  satisfactory  method  of  fixation  in  fractures  below  the 
middle  of  the  shaft  is  one  in  which  internal  and  external  plaster 
splints  are  used,  as  shown  in  Fig.  215.  These  splints  are  made  of 
plain  gauze  (from  fifteen  to  twenty  ply)  and  should  be  reinforced 
at  the  elbow  by  the  insertion  of  additional  layers  of  gauze  between 
the  layers  of  the  splint.  The  external  splint  extends  from  a  point 
well  up  on  the  shoulder,  along  the  back  of  the  arm  and  forearm  to 
the  wrist,  while  the  internal  splint  extends  from  just  below  the 
axillary  fold  to  the  wrist  on  the  anterior  aspect  of  the  upper 
extremity.  They  are  applied  to  the  injured  member  while  wet  and 
rapidly  secured  in  position  with  a  roller  bandage.  The  surgeon 
holds  the  fragments  in  proper  reduction  until  the  plaster  has  set. 
Specific  instructions  should  be  given  to  the  patient  and  his  attend- 
ants not  to  allow  the  splints  to  be  covered  with  clothing  or  bed 


116  FRACTURES   AND   DISLOCATIONS 

covers  for  at  least  twenty-four  hours  so  tlie  plaster  may  beconie 
thoroughly  dried  out.  One  or  two  foldeil  towels  should  be  placed 
between  the  arm  and  the  body,  and  a  liglit  swathe  used  encircling 
the  chest  and  injured  meml)er.  The  following  day  the  splints 
should  be  removed  one  at  a  time,  lined  with  a  layer  of  sheet  cotton 
and  re|)laced.  The  splints  should  then  be  secured  in  position  by 
means  of  strips  of  adhesive  plaster  encircling  the  arm.  The  body 
swathe  may  be  used  in  securing  the  arm  by  the  side,  or  strips  of 
adhesive  may  be  used  for  this  purpose.  Sufficient  padding  should 
be  placed  in  the  external  splint  in  the  I'cgion  of  the  olecranon  to 
avoid  chating  and  discomfort.  This  dressing  is  quite  secure  but 
requires  careful  watching  to  avoid  strangulation  when  swelling 
sets  in.  It  is  of  particular  advantage  in  compound  fractures  of 
the  lower  end  of  the  humeral  shaft  sinc^e  the  arm  may  be  perma- 
nently secured  to  one  splint  while  the  other  is  removed  daily  for 
inspection  and  dressing  of  the  wound. 

After  the  arm  is  immobilized  (whatever  the  type  of  dressing 
may  be)  an  X-ray  should  be  taken,  when  possible,  to  verify  the 
diagnosis  and  to  determine  the  accuracy  of  reduction. 

When  overriding  deformity  cannot  be  corrected  by  solid  engage- 
ment of  the  fractured  ends  weights  may  be  attached  to  the  elbow 
to  control  the  action  of  the  biceps  and  triceps.      (Fig.  214.) 

The  use  of  extension  may  be  indicated  in  some  cases  if  employed 
in  the  recumbent  position,  but  as  an  ambulatory  method  it  is,  in 
the  author's  opinion,  entirely  too  haphazard  and  untrustworthy  to 
be  relied  upon,  notwithstanding  statements  to  the  contrary.  It  may 
be  stated  as  a  rule  that  fractures  of  the  shaft  requiring  permanent 
extension  to  maintain  reduction  should  be  submitted  to  operation, 
and  the  fragments  wired  or  plated  in  position.  If  ambulatory 
extension  is  employed,  and  fails,  we  have  a  condition  of  deform- 
ity which  we  know  only  too  well  might  have  been  prevented  by 
proper  operative  intervention. 

Operative  Treatment. — Fractures  of  the  humeral  shaft  are  fre- 
quently of  the  oblique  or  spiral  type  and  accurate  reduction  is 
often  impossible  without  open  incision  and  internal  fixation.  The 
frequency  with  which  one  sees  deformity  following  fractures  of 
the  humeral  shaft  treated  by  non-operative  methods,  indicates  the 
value  of  open  incision  in  the  treatment  of  breaks  in  this  region. 

It  is  usually  best  to  approach  the  bone  through  an  external  longi- 
tudinal incision  of  sufficient  length  to  allow  free  access  for  manipu- 


FRACTURES   OP    SHAFT   OF   HUMERUS 


117 


lation  and  reduction.  The  greatest  care  should  be  used  to  avoid 
injury  to  the  niusculo-spiral  nerve  in  making  the  iiieision  and  in 
accomplishing  reduction  and  fixation.  Destruction  of  the  function 
of  this  nerve  will  be  more  disastrous  to  the  patient  than  non-union 
of  the  fragments  or  union  with  deformity.  It  should  be  kept  in 
mind  therefore  that  it  is  possible  for  tlie  surgeon  to  i)roduce  an 


Fig.    158 


Fig.  158. — Rontgenogi'am  of  spiral  fracture  of  humerus  after  two  attempts  at  re- 
duction.     Rotary    and  lateral   deformity  present. 

Fig.  159. — Same  case  after  operation,  showing  fragments  held  in  reduction  by  two 
wires.  The  lower  wire  encircles  the  bone  while  the  other,  at  a  higher  level,  penetrates 
the  shaft  and   secures  leverage  for  the  lower  wire. 

injury  which  is  far  worse  than  the  condition  which  he  is  operating 
to  correct ;  accordingly  the  course  of  the  musculo-spiral  nerve  should 
be  thoroughly  appreciated  before  operation  in  this  region  is 
attempted. 

After  the  fragments  have  been  exposed  the  nature  of  the  fracture 
is  accurately  ascertained,  reduction  accomplished  and  the  best 
method  of  fixation  determined.  Each  case  must  be  considered  by 
itself,  and  the  nature  of  the  deformity  fully  appreciated  before 


118 


FRACTURES    AND    niST.OOATIONS 


Fig.  160. — X-ray  of  same  bone  after  it  had  been 
1  inioved  from  soft  tissues.  Note  the  density  and  dis- 
position of  the  callus  nine  months  after  operation 
and  compare  this  plate  with  the  photographs  of  the 
lione  shown  in  Figs.   161,    162   and  163. 

Figs.  161,  162  and  163. — Same  case  as  shown 
ill  Figs.  158,  159  and  160.  Patient  had  suffered 
from  chronic  chorea  for  past  twenty-five  years  and 
susttiined  fracture  as  a  result  of  the  staggering  gait 
wliitli  caused  the  fall.  Fixation  was  particularly  dilli- 
cult  on  account  of  the  nature  of  the  fracture  and  tlie 
choreoid  spasms  and  wiring  was  resorted  to.  Nine 
inontlis  later  patient  died  in  the  terminal  dementia 
following  Huntingdon's  chorea  and  humerus  was  ob- 
tained at  autopsy.  By  comparing  this  specimen  with 
I'igs.  158,  159  and  160  the  disposition  of  the  callus 
I  overing  the  wire  will  be  readily  appreciated.  Tlie 
wire  A.  encircling  the  shaft  has  been  covered  by 
c  :  Uus  where  it  crosses  the  line  of  fracture.  The  wire 
/.'.  was  passed  tlirough  a  drill  liole  in  both  fragments 
and  did  not  encircle  the  shaft;  this  wire  also  is  cov- 
el  ed  by  callus  where  it  crosses  the  line  of  fracture, 
licstoration  of  function  was  complete  some  montlis 
liiior  to  death.  The  dotted  outline  shows  wlicre  the 
nui.-culo-spiral  nerve  crosses  the  bone  in  tlie  fresh 
specimen:  wire  A.  was  originally  passed  between  the 
nerve   and   the  bone. 


Fig.    160. 


Fig.    162. 


A 
Fig.    163. 


FRACTURES   OF    SHAFT   OF    HUMERUS  119 

internal  fixation  is  employed.  Lateral  displacement  and  over- 
riding deformity  in  spiral  fractures  can  usually  be  prevented  by 
a  wire  encircling  the  shaft  and  including  both  fragments.  (See 
Figs.  158  and  159.)  A  second  wire  is  then  placed  a  short  distance 
from  the  first  to  secure  the  proper  leverage  in  preventing  angular 
deformity.  In  passing  the  circular  wire  about  the  shaft  some  form 
of  hook  (such  as  shown  in  Fig.  826)  should  be  used  to  avoid  includ- 
ing the  musculo-spiral  nerve.  The  Lane  plate  has  been  used  in 
this  region  with  most  satisfying  results  and  has  much  to  commend 
it  (see  page  766). 

After-Treatment. — The  after-care  of  fractures  of  the  humeral 
shaft  is  as  important  as  reduction.  The  bone  is  deeply  seated  and 
difficult  to  immobilize  and  the  dressings  require  daily  inspection 
and  adjustment  during  the  first  ten  days.  Undue  constriction  of 
the  parts  must  be  avoided  and  still  the  dressings  must  be  tight 
enough  to  properly  support  and  immobilize  the  arm.  In  other 
words,  the  arm  is  changing  in  size  because  of  the  swelling,  and  the 
dressings  must  be  made  to  vary  accordingly,  so  they  may  fulfill 
their  proper  function.  AVhen  fixation  is  satisfactory  union  should 
be  present  at  the  end  of  four  weeks  in  children,  and  in  from  five 
to  six  weeks  in  adults.  The  older  the  patient  the  slower  the  bone 
will  be  in  uniting.  After  the  removal  of  splints  the  arm  should  be 
carried  in  a  sling  for  another  two  or  three  weeks.  Massage,  early 
passive  motion  and  hot  applications  will  hasten  the  restoration  of 
function.  The  arm  should  not  be  subjected  to  excessive  strain  for 
three  to  four  months  following  the  injury. 

Prognosis. — In  children  and  healthy  young  adults  the  restora- 
tion of  function  should  be  rapid  and  complete,  if  proper  reduction 
and  immobilization  have  been  carried  out,  and  union  is  usually  firm 
at  the  end  of  four  weeks.  In  adults  five  to  six  weeks  is  necessary. 
Non-union  is  more  common  here  than  in  any  other  bone  in  the  body, 
and  is  usually  due  to  incomplete  reduction  or  lack  of  proper  im- 
mobilization. Laceration  of  the  musculo-spiral  nerve  at  the  time 
of  injury  will  be  followed  by  paralysis  and  contractures,  if  not 
exposed  and  repaired.  Even  when  the  ends  are  united  recovery  is 
tedious  and  often  incomplete.  The  development  of  paralysis  of 
this  nerve  during  the  after-treatment  may  be  due  to  compression 
by  the  callus  and  unless  relieved  by  operation  gives  a  bad  prognosis. 


CHAPTER  IX. 

FRACTURES  OF  THE  LOWER  END  OF  THE  HUMERUS. 

Surgical  Anatomy. — The  lower  end  of  the  humerus  articulates 
with  two  boni's;  the  types  of  these  artieulatious  are  entirely  dilt'(;rent 
and  the  fractures  occurring  in  this  region  are  complex.     The  lower 


Fig.    164    (top) 


Viti.    166. 


Fig.    164. — Anterior    surface   of   lowor    end    of    right    luuiierus.      J.E.,    internal    epicon 
dyle;    C,   capitelluni;    T.,   trochlea. 

Fig.    165. — Lower   end    of    left    humerus    seen    from   below.      T.,   trochlea;    C,    capitel- 
lum;    I.E.,   internal   epicondyle ;    E.E.,    external   epicondyle. 

Fig.    166. — Me.sial    aspect    of    lower    end   of    left    humerus.      I.E.,    internal   epicondyle; 
E.T.,  edge  of  trochlea. 

end  of  the  bone  curves  forward  and  is  flattened  from  before  back- 
ward. The  articular  surfaces  may  be  described  roughly  as  a 
cylinder  mounted  on  the  lower  end  of  the  shaft,  with  the  axis  of  the 
cylinder  nearly  transverse  to  the  long  axis  of  the  shaft.     The  outer 

120 


FRACTTTRER    OF    LOWER   END    OF    TIUMERTTS 


121 


end  of  the  cylinder  is  at  a  slightly  higher  kivel  than  the  inner  end. 
When  the  elbow  is  fully  extended  the  arm  and  forearm  are  not  in 
the  same  straight  line  but  form  an  angle  of  about  170  degrees. 
The  difference  between  this  angle  and  a  straight  line  is  10  degrees, 
half  of  which  is  caused  by  the  obliquity  of  the  articular  surfaces  of 
the  lower  end  of  the  humerus,  while  the  other  half  is  the  result  of 
the  position  of  the  bones  of  the  forearm.  In  complete  extension, 
therefore,  we  have  the  "carrying  angle"  while  in  complete  flexion 
the  forearm  comes  in  contact  with  and  folds  directly  upon  the  arm. 
When  the  fragments,  in  fractures  of  the  lower  end  of  the  humerus, 


Fig.    167.  Fig.    168. 

Fig.  167. — "Crescentie"  fracture  of  lower  end  of  humenis.  Slight  lateral  displace- 
ment. 

Fig.  168. — "Crescentie"  fracture  of  lower  end  of  humerus  with  more  pronounced 
lateral  displacement. 


are  allowed  to  unite  in  deformity  there  may  be  a  disturbance  in 
the  carrying  angle  which  is  apparent  when  the  arm  is  extended, 
and  in  addition  there  may  also  be  a  deformity  in  which  the  fore- 
arm does  not  fold  directly  against  the  arm  in  acute  flexion.  The 
carrying  angle  varies  considerably  in  different  individuals  and  the 
examination  should  therefore  include  comparison  with  the  unin- 
jured elbow. 

A  certain  amount  of  hyperextension  is  normal  in  the  elbow,  and 
by  means  of  this  position  longitudinal  stress  may  be  borne  by  the 
upper  extremity  independently  of  the  extensor  muscles,  the  action 
resembling  that  seen  in  the  knee  when  the  joint  is  hyperext ended. 


122  FRACTURES   AND   DISLOCATIONS 

The  lower  end  of  the  humerus  is  deserving  of  detailed  considera- 
tion so  that  the  fractures  occurring  in  tliis  portion  of  tlie  bone  may 
be  more  thoroughly  understood. 

The  external  condyle  (epicondyle)  is  a  small,  tubercular  eminence 
situated  just  above  and  a  little  external  to  the  capitellum.  It 
affords  attachment  to  the  external  lateral  ligament  and  some  of 
the  extensor  and  supinator  nuiscles  of  the  forearm.  It  is  rarely 
fractured  without  at  least  a  portion  of  the  capitellum  being  included 
with  the  fragment. 

The  capitellum  is  the  rounded  eminence  occupying  the  outer 
part  of  the  articular  surface.     It  articulates  with  the  head  of  the 


Fisf.    170. 


Fig.    169. — Vertical    fracture    of    lower    end    of    luunenis    separating    external    condyle 
from  remainder  of  bone. 

Fig.   170. — Fracture    of    the    external    condyle    with    lateral    displacement    of    elbow. 
Fracture  of  the  olecranon  present  but  not  discernible  from  this  angle. 

radius,  and  is  rarely  injured  except  when  involved  in  some  of  the 
more  common  fractures  of  the  external  condyle.  The  radius  artic- 
ulates below  with  the  carpus  and  above  with  the  capitellum,  and  in 
falls  on  the  hand  violence  is  transmitted  directly  to  the  capitellum 
through  the  radius.  This  type  of  violence,  however,  is  much  more 
likely  to  produce  Colle's  fracture  or  a  break  in  the  shaft,  neck  or 
head  of  the  radius.  The  oblicpiity  of  the  fibres  of  the  interosseous 
ligament  enables  the  ulna  to  absorb  a  portion  of  the  shock  when 
violence  is  sustained  in  this  way.  The  capitellum  occupies  only  the 
front  and  lower  part  of  the  bone. 

The  inner  portion  of  the  articular  surface  is  taken  uj)  by  the 


FRACTURES   OF    LOWER   END    OF    HUMERUS 


]23 


trochlea  which  articulates  with  the  greater  sigmoid  cavity  of  the 
ulna.  It  presents  a  pronounced  groove  running  from  before  back- 
ward which  is  bounded  on  either  side  by  prominent  ridges,  the 
inner  being  the  most  marked  and  extending  to  a  lower  level.     Tlie 


Fig.    171. 


Fig.    172. 


Fig.  171. — T-fracture  of  lower  end  of  humerus.  Pronounced  inward  and  backward 
displacement  of  lower  fragments. 

Fig.  172. — "Crescentic"  fracture  of  lower  end  of  liumei-us  witli  lateral  and  back- 
ward  displacement   of   lower   fragment. 


Fig.    173.  Fig.    174. 

Fig.   173. — Supracondylar  fracture  with  pronounced  inward  and  backward  displace- 
ment of   lower   fragment. 

Fig.   174. — ^Same  case  after  reduction. 

trochlea  is  slightly  spiral  so  that  the  posterior  end  is  a  little  external 
to  the  anterior  extremity.  Just  above  the  anterior  end  of  the 
trochlea  is  situated  the  coronoid  fossa  which,  during  flexion  of  the 
elbow,  receives  the  process  on  the  ulna  of  the  same  name.     On  the 


124 


FRACTURES   AND   DISLOCATIONS 


posterior  aspect  of  the  bone  in  tlic  same  corresponding  position  is 
fonnd  the  olecranon  fossa,  'riiese  two  fossip  are  ordinarily  sep- 
arated I)y  only  a  thin  layer  of  bone  and  when  the  de]n-essi(nis  are 


F\s.    175 


Fig.    ]T(i 


Pi?.    17.5. 
Fig.    176. 


'Crescent ic"    fracture   with   backward   and    rotary   displacement. 

Fracture    of   lower    end    of    humerus    with    backward    and    rotary    displace- 


Fig.    177. 

Fig.  177. — Fracture  of  lower  end  of  humerus.  Deformity  not  apparent  in  antero- 
posterior view. 

Fig.  178. — Same  case  seen  laterally.  Slight  backward  displacement  of  lower  frag- 
ment. 

well  marked  the  bone  may  be  perforated,  forming  the  supracondylar 
foramen.  These  two  fossse  materially  weaken  the  constniction  of 
the  lower  end  of  the  humerus  and  are  usually  entered  by  transverse 


FRACTURES   OF    LOWER   END    OF    HUMERUS 


125 


fractures  in  this  region,  and  by  vertical  fractures  involving  the 
articular  surfaces. 

The  internal  condyle  (epitrochlea)  is  much  more  prominent  and 
larger  than  the  external  condyle,  and  affords  attachment  to  tlie 
internal  lateral  ligament  and  some  of  the  pronators  and  flexors  of 
the  forearm.  It  is  more  easily  broken  than  the  external  condyle. 
Directly  behind  this  process  is  a  groove  for  the  ulnar  nerve  whicli 
is  not  infrequently  injured  in  fractures  of  the  internal  condyle. 

The  manner  in  which  the  lower  epiphysis  of  the  humerus  is 
ossified  is  of  importance  in  explaining  epiphyseal  separations  in 
this  region,  though  the  resultant  conditioiis  are  treated  in  a  manner 
similar  to  fractures  of  the  same  parts.  At  birth  the  epiphysis  is 
entirely  cartilaginous  and  throws  no  shadow  under  the  X-ray, 
while  the  lower  end  of  the  diaphysis  is  rounded.      (See  Fig.  251.) 


Fig.    179. 


Fi:;.    ISO. 


Fig.    179. — EpipliYsenl   separation   of   epitrochlea. 
Fig.    ISO. — Lateral  view  of  same  case. 


Before  the  end  of  the  first  year  the  center  for  the  capitellum 
makes  its  appearance.  At  the  sixth  year  the  center  for  the  internal 
condyle  is  seen;  during  the  eleventh  year  the  trochlea  begins  to 
ossify  and  the  center  for  the  external  condyle  is  first  seen  during 
the  twelfth  year.  The  outer  three  centers  usually  fuse  with  each 
other  and  join  the  diaphysis  during  the  fifteenth  year,  before  the 
center  for  the  epitrochlea  becomes  continuous  with  either  epiphysis 
or  diaphysis.  The  internal  condyle  joins  the  rest  of  the  bone  at 
about  the  eighteenth  year.  During  the  latter  part  of  the  develop- 
ment of  the  lower  end  of  the  humerus  the  diaphysis  is  seen  to 
project  progressively  further  into  the  epiphysis  so  that  it  comes 
nearly  to  the  surface  between  the  centers  for  the  internal  epicondyle 
and  trochlea.  The  order  in  which  these  centers  join  the  shaft  and 
the  thinning  of  the  epiphysis  between  the  trochlea  and  internal 


126 


FRACTURES   AND   DISLOCATIONS 


epicondyle  account  for  the  relative  frequency  of  epiphyseal  sep- 
arations of  the  internal  epicondyle. 

The  ligaments  about  the  elbow  phiy  an  important  i)art  in  pro- 
duction of  fractures.  AVith  the  elbow  partially  flexed,  abduction 
or  adduction  of  the  forearm  produces  rotation  of  the  humerus. 
With  the  elbow  fully  extended,  liowever,  there  is  practically  no 
rotary  ett'ect  on  the  liumcius  but  instead  extreme  tension  is  pro- 
duced on  one  of  the  lateral  ligaments.  If  the  forearm  is  abducted 
the  head  of  the  radius  is  forced  against  the  capitelluiu  and  the 
internal  lateral  ligament  is  placed  under  tension.     If  the  violence 


Fi^;.    Irt2. 


Fis.   is; 


Fig.    181. — Fracture  of  internal  epicondyle. 

Fig.   182. — Separation   of   epiphysis   of   external   condyle. 

Fig.   183. — Separation  of  epiphysis  of  internal  epicondyle. 


is  sulBcient  the  capitellura  is  fractured,  or  the  bone  supporting  it  is 
broken  off  from  the  remainder  of  the  lower  end  of  the  hum-erus. 
Instead  of  either  of  these  lesions  tlie  internal  lateral  ligament  may 
suffer  rupture,  or  an  equivalent  fracture  of  the  internal  ejueondyle 
or  trochlea  may  take  place.  When  the  elbow  is  extended  and  the 
forearm  forcibly  adducted  the  reverse  mechanism  obtains. 

If  the  forearm  is  forcibly  extended  beyond  the  normal  limita- 
tions of  motion  the  usual  result  is  either  rupture  of  the  ligaments 
or  fracture  of  the  lower  end  of  the  humerus,  with  backward  dis- 
placement of  the  fragment.  A  much  more  exceptional  fracture  is 
one  produced  by  extreme  flexion. 

The  types  of  fracture  occurring  in  the  lower  end  of  the  humerus 
are  numerous,  and  have  for  the  most  part  been  named  according 


FRACTURES   OF   LOWER   END   OF    HUMERUS  3  27 

to  the  portion  of  the  bone  involved.     The  terminology  employed 
by  different  authors  varies  and  the  result  has  been  rather  confusing. 
The  usual  fractures  occurring  in  this  region  are : 

Fracture  of  the  epicondyle. 

Fracture  of  the  external  condyle  including  the  capitellum. 

Fracture  of  the  internal  condyle  including  the  trochlea. 

Fracture  of  the  epitrochlea. 

Dia-conclylar  fracture,  the  break  passing  transversely  tlirough 
the  condyles. 

Supra-condylar  fracture,  the  break  passing  just  al)ove  the  con- 
dyles. 

T-  or  Y-fraeture,  in  which  a  vertical  break  divides  the  lower 
fragment  of  a  supra-  or  dia-condylar  fracture. 

Comminuted  fracture  of  the  lower  end  of  the  humerus,  in  which 
the  lower  end  of  the  bone  is  so  broken  up  that  it  is  difficult 
to  recognize  any  particular  type  of  fracture. 

Fracture  limited  to  the  capitellum  as  a  result  of  violence  trans- 
mitted tlirough  the  radius  in  falls  on  the  hand. 

Epiphyseal  separations  as  described  above. 

It  will  be  noted  that  all  of  the  above  fractures,  except  the  last 
two  named,  may  be  described  as  either  ''transverse"  or  "vertical" 
or  a  combination  of  these  two.  The  supra-condylar  and  dia- 
condylar  fractures  are  essentially  transverse,  while  the  fractures 
involving  the  condyles  and  traversing  the  articular  surfaces  are 
vertical.  The  Y-  or  T-fracture  shows  both  vertical  and  transverse 
elements.  Nearly  all  transverse  fractures  pass  through  the  ole- 
cranon fossa  as  do  the  vertical  fractures  involving  the  articular 
surfaces. 

Transverse  fractures  are  usually  the  result  of  forced  hyper- 
extension  of  the  elbow,  and  the  lower  fragment  is  almost  invariably 
displaced  backward.  In  the  typical  transverse  fracture  the  lower 
fragment  is  crescentic,  the  concavity  looking  upward.  This  type 
of  fracture  has  frequently  been  mistaken  for  an  epiphyseal  sep- 
aration in  spite  of  the  fact  that  there  should  be  no  difficult}^  in 
differentiating  the  two  conditions  when  the  X-ray  is  employed. 

The  upper  end  of  vertical  fractures  may  cross  either  the  internal 
or  external  supracondylar  ridge,  but  the  lower  end  of  the  break  is 
frequently  placed  so  that  the  trochlea  is  separated  from  the  capitel- 
lum.    This  separation  of  the  two  articular  surfaces  on  the  lower 


128  FRACTURES   AND   DISLOCATIONS 

end  of  the  humerus  allows  a  flail-like  lateral  mobility  at  the  elbow 
M'hieh  is  characteristic  of  the  injury.  A  rare  disi)lacpinent,  some- 
times seen  in  transverse  fractures,  is  one  first  described  by  Posadas, 
in  which  the  lower  fragment  is  displaced  forward  wliile  the  bones 
of  the  forearm  arc  luxated  backward. 

Wli(>n  the  condyles  are  sepai'ated  fi'om  each  other  by  a  vertical 
ffiU'ture,  one  or  liotli  of  tlie  condyles  may  be  displaced  so  that  the 
n-lation  of  the  tlii'ee  l)ony  prominences  is  disturbed. 

In  the  normal  elbow  the  prominence  of  the  olecranon  and  the  two 
condyles  should  be  about  on  the  same  sti'aight  line  M'hen  the  elbow 
is  fully  extended.  The  olecranon  is  a  trifle  nearer  the  inner  con- 
dyle. AVhen  the  elbow  is  in  a  ])osition  of  acute  flexion  these  tliree 
bony  prominences  should  occupy  the  apices  of  an  eciuilateral  tri- 
angle. This  anatomical  relation  is  of  great  value  both  in  diagnosis 
and  treatment.  The  inuscles  attached  to  the  condyles  may  exert  a 
displacing  action  when  either  of  these  processes  is  detached.  In 
vertical  fractures  the  condyles  arc  usually  further  apart  than  they 
should  be,  and  the  condyle  on  the  detached  fragment  may  be  dis- 
placed forward,  backward,  upward  or  downward.  In  any  fracture 
in  which  the  lateral  stability  of  the  elbow  is  destroyed  the  carrying 
angle  is  lost  as  the  arm  hangs  by  the  side,  and  if  the  condition  is 
severe  the  forearm  may  diverge  to  the  inner  side,  producing  the 
familiar  "gunstock  deformity,"  or  cubitus  varus.  This  deformity 
may  occur  with  any  of  the  transverse  fractures  and  with  the  vertical 
fractures  involving  the  articular  surfaces.  Immediately  following 
the  accident  this  deformity  is  due  to  gravity  and  to  the  position 
occupied  by  the  displaced  fragment  or  fragments.  If  the  frag- 
ments are  not  replaced  and  recurrence  of  displacement  prevented 
the  deformity  will  become  permanent  when  union  takes  place. 

In  the  rare  T-fracture  or  in  extensive  comminution  of  the  lower 
end  of  the  humerus  the  lateral  stability  of  the  joint  is  most  com- 
pletely broken  up  since  both  condyles  are  separated  from  the  shaft 
and  from  each  other,  and  the  line  of  fracture  divides  the  articular 
surface.  This  type  of  fracture  usually  results  from  a  fall  directly 
on  the  flexed  or  semiflexed  elbow. 

Symptoms. — The  symptoms  accompanying  fractures  of  the  lower 
end  of  the  humerus  vary  considerably  according  to  the  position  of 
the  fracture  and  tlie  severity  of  the  lesion.  Pain,  swelling,  local 
tenderness,  loss  of  function  and  deformity  are  all  present  though 
they  vary  somewhat  with  the  nature  of  the  fracture.     The  traumatic 


FRACTURES    OF    LOWER   END    OF    ITTJMERTTS 


129 


reaction  following  fractures  of  tlu;  lower  end  of  llic,  liumerus  is 
usually  pronounced,  and  a  few  days  following  the  a(;cident  the 
region  of  the  elbow  may  be  covered  with  ))lel)s  containing  blood 
or  serum.  Ecchymosis  usually  develops  within  twelve  to  twenty- 
four  hours  and  may  be  extensive.  The  loss  of  function  is  usually 
complete  following  transverse  fractures  or  those  which  involve  the 
articular  surfaces.  In  isolated  fracture  of  either  the  epicondyle  or 
epitrochlea  the  loss  of  function  may  be  surprisingly  slight.  The 
patient  will  be  able  to  use  the  elbow  to  some  extent  though  of  course 
the  action  of  the  part  is  somewhat  limited  by  pain. 

The  symptoms  peculiar  to  the  different  fractures  in  this  region 
v\'ill  be  considered  in  detail. 


Fig.  184. — Fracture  of  e\tei  n.il  epicondyle  with  upward  displacement  of  fragment. 
Prominence  on  external  aspect  of  elbow  suggestive;  palpation  reveals  fragment.  Joint 
is  intact,   there  being  no  involvement  of   articular   surface.      Condition   rare. 


Fractures  of  the  epicondyle  (fractures  in  which  the  joint  is  not 
entered  and  the  capitellum  remains  intact)  are  extremelj^  rare  and 
the  symptoms  are  not  pronounced.  Moderate  local  swelling  and 
tenderness  in  the  region  of  the  external  condyle  is  present.  The 
fragment  may  remain  in  position  or  may  be  displaced  in  an,y  direc- 
tion. When  deformity  exists  the  fragment  is  usuallj^  displaced 
downward.     The  detached  particle  of  bone  can,  as  a  rule,  be  directly 


130 


FRACTURES   AM)    DISLOCATIONS 


palpated  and,  if  tlie  fractured  surfaces  eau  be  rubbed  together, 
crepitus  will  be  noted.  Crepitus  may  be  difficult  to  elicit  if  the 
fragment  is  not  displaced  and  the  swelling  is  pronounced.  De- 
tachment of  the  epicondylc  will  destroy,  to  a  greater  or  less  extent, 
tlio  fuiictinn  of  tlu^  cxtci-iial   l.-itcrnl   li^jimctit  and  accordingly  the 


Figs.  185  aiul  186. — Two  views  of  .i  l'i;ii1niv  of  lower  end  of  humerus  witliout  the 
characteristic  backward  displacement  of  lower  fiaament.  Note  prominence  of  e.\ternal 
epicondyle  which  is  detached.  The  .ioint  reni;uns  intact  and  hence  the  ahsence  of  de- 
formity such  as  seen   in    l<'igs.   ISS   and   189. 


Fig.  187. — Splitting  of  lower  end  of  humerus  with  separation  of  external  condyle. 
Gun-stock  deformity  and  abnormal  lateral  mobility.  Picture  taken  a  few  hours  follow- 
ing accident. 

lateral  stability  of  the  elbow  may  be  somewdiat  disturbed.     A  vary- 
ing degree  of  abnormal  adduction  of  tlie  elbow  is  often  possible. 

Fractures  of  the  e.rternal  condyle  (vertical  fractures  which  enter 
the  joint  and  include  the  capitellum  in  the  detached  fragment)  are 
much   more   common   than   fractures   of   the   epicondyle   and   the 


FRACTURES    OF    IjOWRR   END    OF    irUMERTTS  131 

symptoms  arf^  decidedly  more  pronounced.  Pain  is  severe,  loss  of 
function  complete  and  swelling  pronounced.  The  lateral  stability 
of  the  elbow  is  usually  completely  lost  and  the  joint  is  flail-like 
in  a  transverse  direction.  Crepitus  is,  as  a  rule,  recognized  as  soon 
as  the  parts  are  manipulated.  On  palpating  the  condyles  the  epi- 
condyle  is  found  detached  from  the  humerus,  while  the  epitroclilea 
is  continuous  with  the  rest  of  the  bone.  The  forearm  is  usually 
supported  by  the  uninjured  member  and  the  patient  is  reluctant  to 
release  it  for  examination.  When  the  arm  hangs  by  the  side  the 
helplessness  of  the  member  is  apparent  and  the  usual  "gunstock" 
deformity  is  recognized  at  a  glance.  The  fragment  is  usually  dis- 
placed downward  and  may  be  so  rotated  that  the  fractured  surfaces 
are  no  longer  parallel  and  facing  each  other  (see  Fig.  218). 

Fractures  of  the  internal  condyle  (vertical  fractures  entering  the 
joint  and  separating  all,  or  a  portion,  of  the  trochlea  from  the 
remainder  of  the  bone) .  The  symptoms  are  similar  to  those  already 
described  in  the  preceding  type  except  that  the  inner  side  of  the 
elbow  is  the  most  painful  and  tender,  and  the  internal  condyle  is 
found  to  be  the  movable  part.  Loss  of  lateral  stability  is  even 
more  pronounced  than  in  fracture  of  the  external  condyle. 

Fracture  of  the  epitrochlea  (a  vertical  fracture  separating  the 
internal  epicondyle  from  the  remainder  of  the  bone  without  entering 
the  joint  or  involving  the  trochlea)  is  not  an  uncommon  injury, 
and  since  neither  the  joint  cavity  nor  the  articular  surfaces  are 
involved  the  symptoms  are  usually  slight.  There  is  some  local 
tenderness  and  pain  on  the  inner  side  of  the  elbow,  and  ecchymosis 
is  usually  seen  within  the  first  day.  Flexion  and  extension  of  the 
elbow  are  not  painful  except  in  as  much  as  they  disturb  the  detached 
fragment.  Extreme  extension  or  acute  flexion  may  be  attended  by 
pain.  Local  swelling  is  usually  present.  The  symptoms  are  often 
so  slight  that  the  condition  is  not  infrequently  mistaken  for  a 
sprain  and  treated  as  such. 

Supracondylar  and  diacondylar  fractures  are  similar  conditions 
and  the  symptoms  so  resemble  each  other  that  they  will  be  de- 
scribed together.  Swelling,  pain,  tenderness,  loss  of  function, 
crepitus,  and  mobility  are  present  as  in  vertical  fractures  involving 
the  articular  surfaces.  Loss  of  carrying  angle  and  even  gunstock 
deformity  are  usually  prominent  symptoms.  The  deform  it}-  is 
often  characteristic,  the  bones  of  the  forearm  and  humeral  frag- 
ment being  displaced  backward  in  such  a  way  as  to  produce  a  strong 


132 


FRACTURES   AND   DISLOCATIONS 


Fis:.  188. — Transverse  fraclure  of  tlie  lower  end  of  the  humerus.  Note  the  back- 
Wind  diKphitenieiit  of  the  elbow.  Palpation  reveals  the  three  bony  prominences  all  dis- 
placed backward  without  disturbance  in  tlieir  relative  positions.  Sigmoid  cavity  of  ulna 
not  empty,  as  in  Fig.  229.  Picture  taken  about  twent\-four  hours  following  accident. 
Note  swelling  and  slight  ecchymosis. 


/^< 


Fig.  189. —  Same  cai^i'  in  i-itliiig  ]Hisiliiiii.  Note  ihat  lice  deformity  persists  with 
change  of  position.  The  elbow  is  Hail-liUe  yet  tlie  action  of  the  biceps  and  triceps  pro- 
duce  and   maintain    the   deformity. 


FRACTURES    OF    LOWER   END    OF    HUMERUS 


383 


Fig.    190.  Fig.    191. 

Figs.    190   and   191. — X-ray   plates  of   case  shown  in  Figs.   188   and   189   after   incom- 
plete  reduction. 


P"*!!* 


Fig.    192. 


Fig.    193. 


Figs.  192  and  193. — Compound  comminuted  fracture  of  lower  end  of  humerus. 
Note  the  backward  and  inward  displacement  which  is  characteristic.  Forearm  is  cov- 
ered with  blood  which  accounts  for  its  darkened  condition  in  the  photograph.  Arrow 
points  to  the  wound  just  above  and  behind  the  elbow.  Picture  taken  about  one  hour 
after  injury. 


134 


FHACTITRES    AN1>    DISLOCATIONS 


reseHil)laiiee  to  backward  dislocations  of  the  elbow  (see  page  159). 
The  character  of  the  deformity  is  well  shown  in  Figs.  188  and  189. 
On  palpation  the  two  condyles  are  fonnd  to  be  no  longer  continuous 
with  the  shaft  of  the  humerus  thongh  they  are  continuous  with  each 
other  and  move  togc^ther.     If  the  upper  end  of  the  ulna  is  palpated 


Fig.    194. 


Figs.   194   and   19.5. — Compound     comminuted     fracture     of     tlie     lower     end    of     tiie 
humerus.      Note   the    deformity    and    flail-like   condition. 

the  greater  sigmoid  cavity  will  be  found  occupied  by  tlie  lower  end 
of  the  humerus  and  not  emi)ty  as  in  backward  luxation.  The  lateral 
stability  of  the  elbow  is  destroyed.  The  characteristic  deformity  of 
a  supra-  or  dia-condylar  fracture  is  first  the  backward  displacement 
of  the  elbow  and  second  the  "gunstoek"  deformity.  (See  Figs. 
192  and  193.) 

In  ihe  T-  or  Y-fracture  of  the  lower  end  of  the  humerus  or  in 


FRACTURES    OF    liOWER   END    OF    TrUMRR[TS 


135 


cases  in  which  the  lower  end  of  the  hone  is  extensively  comminuted 
practically  all  the  symptoms  of  the  above  described  transverse  and 
vertical  fractures  are   |)resent  in   exaggerated  form.     The  lateral 


Figs.  196  and  197. — Old  case  of  gunstock  deformity  and  almost  complete  loss  of 
function  of  elbow  due  to  fractures  above  and  below  the  joint.  X-ray  examination  shows 
supracondylar  fracture  in  lower  end  of  humerus  and  fracture  of  ulna  below  coronoid 
process. 

stability  of  the  elbow  is  more  completely  destroyed  in  these  types 
than  in  other  forms  of  fracture  in  the  lower  end  of  the  humerus. 
The  traumatic  reaction  is  usually  severe  and  the  fracture  is  not 


136 


FRACTURES   AND    DISLOCATIONS 


infrequently  eompound.  On  i)alpation  crepitus  is  readily  recog- 
nized, and  when  the  eonnninution  is  extensive  the  region  of  the 
elbow  may  give  one  the  sensation  of  a  sack  of  marbles.  When  the 
condition  is  compound  the  wound  is  not  infrequently  located  just 
above  the  olecranon  on  the  posterior  aspect  of  the  arm. 

Fracture  limited  to  the  capitellum  is  extremely  rare  and  presents 
no  characteristic  symptoms.  Local  tenderness  and  pain  with  use 
of  the  elbow  are  present,  but  the  condition  is  seldom  recognized 
without  the  aid  of  the  X-rav. 


Fig.    198. 


Fiff.   199. 


Figs.  198  and  199. — Old  case  of  diacondylar  fracture  with  the  usual  backward  dis- 
placement of  elbow.  Deformity  closely  resembles  backward  luxation  of  the  eibow.  The 
characteristic  depressions  at  the  back  of  the  elbow  are  absent  and  palpation  of  the  sig- 
moid determines  that   it  is  not  empty.      (Compare  with  Figs.   225   to   230.) 


Diagnosis. — The  diagnosis  of  fractures  of  the  lower  end  of  the 
humerus  is  based  on  the  symptoms  just  enumerated.  Swelling 
about  the  elbow  is  usually  rapid  in  onset  and  pronounced  following 
fractures  in  this  region,  and  the  earlier  the  surgeon  sees  the  case 
after  the  accident  the  less  difficulty  there  will  be  in  establishing  a 
diagnosis.     Firm,  local,  gentle  and  continued  pressure  in  a  given 


FRACTURES   OF   LOWER   END   OF    HUMERUS 


137 


spot  will  in  many  cases  so  displace  the  fluids  within  the  swollen 
tissues  as  to  render  recognition  of  the  underlying  bone  possible. 

If  there  is  difficulty  in  determining  the  nature  of  the  fracture  the 
examination  should  be  systematically  conducted  so  that  all  the  data 
possible  may  be  gathered  before  the  surgeon  forms  an  opinion  of 
the  condition.  If  the  traumatic  reaction  is  pronounced  it  will 
usually  be  advisable  to  anesthetize  the  patient  before  examining  the 
parts.  The  expense  of  repeated  Rontgenographic  examinations  is 
frequently  objected  to  by  the  patient,  and  under  these  circumstances 
it  may  be  advisable  to  learn  all  that  is  possible  from  a  physical 


200 


Fig.   201. 


Fig.  200. — Examination  of  three  bony  prominences  with  elbows  acutely  flexed.  Note 
the  slight  backward  and  upward  displacement  of  the  patient's  right  internal  condyle. 

Fig.  201. — ^With  full  extension  it  will  be  noted  that  there  is  a  loss  of  carrying  angle 
in  the  patient's  right  arm.  The  left  arm  is  normal.  Old  fracture  of  lower  end  of  right 
humerus. 


examination  under  anesthesia,  reduce  the  fracture  and  then  have 
an  X-ray  plate  taken  to  verify  the  diagnosis  and  the  completeness 
of  reduction  at  the  same  time.  A  careful  inspection  of  the  parts 
is  of  the  greatest  value  and  should  be  done  before  the  arm  is  sub- 
jected to  any  manipulation  whatever.  The  character  of  the  deform- 
ity and  the  attitude  of  the  patient  will  often  be  sufficient  to  indicate 
the  nature  of  the  injury  so  that  the  diagnosis  is  confirmed  by  the 
least  possible  manipulation  and  palpation.  The  less  the  parts  are 
disturbed  and  the  more  gentle  the  manipulation  the  better.  If 
inspection  indicates  the  nature  of  the  injur}^  the  surgeon  should 
examine  the  part  suspected  first.     Otherwise  the  lower  end  of  the 


138  FRACTURES   AND   DISLOCATIONS 

bone  should  be  covered  systematically.  The  external  condyle 
should  be  palpated  and  note  made  of  whether  or  not  the  process 
is  continuous  vvith  tlie  shaft  of  the  humerus  and  the  opi)osite  con- 
dyle. The  same  examination  should  then  be  made  of  the  inner 
condyle.  The  lateral  stability  of  the  elbow  should  next  be  tested 
witli  the  forearm  fully  extended.     In  detei'iniiiiiig  tliis  point  the 


202.  Fig.    203. 


Figs.  202  and  203. — Old  fracture  of  lower  end  of  humerus  with  union  in  deformity. 
Pronounced  gun-stock  deformity  and  shortening  of  arm.  The  positions  of  the  three  bony 
prominences  have  been  marked  and  the  displacement  is  apparent.  A  line  drawn  through 
the  two  condyles  is  not  at  right  angles  to  the  shaft  of  the  humerus.  By  examining  the 
elbow  in  this  position  one  can  tell  the  position  which  the  forearm  will  occupy  when 
extended.  ( See  accompanying  text. )  Function  good  considering  the  deformity.  Case 
first  seen  six  years  after  the  injury   at  which  time  these  photographs  were   taken. 

lower  end  of  the  arm  is  grasped  above  the  elbow  to  steady  the 
humerus  while  the  opposite  hand  grasps  the  wrist  and  an  attempt 
is  made  to  adduct  and  then  abduct  the  forearm.  The  wrist  nor- 
mally moves  inward  in  passing  from  the  position  of  supination  to 
pronation,  and  the  distance  traversed  is  nearly  equal  to  the  breadth 
of  the  wrist.  This  motion,  however,  is  accomplished  entirely  by 
the  low'er  end  of  the  radius  encircling  the  head  of  tlie  ulna  and  in 


FRACTURES   OF   LOWER   END    OP    HUMERUS  139 

no  wise  means  ]ateral  motion  at  the  elbow.     Lateral  motion  does 
not  exist  in  the  normal  elbow. 

The  relation  of  the  three  bony  prominences  of  the  elbow  shoulfl 
be  carefully  noted,  and  if  the  normal  relation  is  disturbed  the 
surgeon  should  determine  which  of  the  prominences  is  displaced. 
The  olecranon  should  be  carefully  palpated  and  its  continuity  with 


Fig.    204. — Another  view  of  case  shown  in  Pigs.   202   and  203,   showing  the  striking 
deformity. 

the  ulnar  shaft  determined.  The  head  of  the  radius  should  be 
palpated  and  note  made  of  whether  or  not  the  head  rotates  with 
the  radial  shaft  during  pronation  and  supination  of  the  forearm. 
The  forearm  should  be  carried  through  its  normal  range  of  motion 
and  any  restriction  of  action  or  pain  should  be  noted. 

The  backward  displacement  accompanying  transverse  fractures 


140 


FRACTURES   AND   DISLOCATIONS 


of  the  lower  end  of  the  humerus  closely  resembles  the  deformity 
seen  in  backward  luxations  of  the  elbow.  In  luxations,  however, 
the  deformity  is  usually  more  pronounced  and  the  sigmoid  cavity 
is  found  empty  on  palpation  (compare  the  appearances  of  the 
cases  shown  in  Figs.  1!)9  and  229).  In  fractures  mobility  is 
increased,  while  in  luxations  it  is  usually  restricted. 


Fig.  205. — Fracture  about  two  inches  above  the  condyles  three  years  after  the 
accident.  Note  the  inward  angular  displacement  of  the  lower  fragment  and  resultant 
gun-stock  deformity.  Paralysis  result  of  injury  to  musculo-spiral  nerve  at  the  level  of 
the  fracture.  Nerve  in.iury"  not  recognized  at  the  time  of  the  injury  and  nothing  done 
subsequently  to  rep.'iir  the  damage.  Patient  has  practically  no  use  of  the  member. 
Case  first  seen  by  author  at  time  of  taking  this  photograph. 

Fractures  of  the  lower  end  of  the  humerus  must  be  differentiated 
from 

Dislocations  of  the  elbow. 

Dislocations  of  the  ulna  alone, 

Dislocations  of  the  radial  head. 

Fractures  of  the  olecranon, 

Fractures  of  the  coronoid  and  ulna  below  the  elbow, 

Fractures  of  tlie  radial  head,  neck,  or  shaft. 

Simple  sprain  of  the  elbow. 


FRACTURES    OP    LOWER   END    OP    IIUMERtlft 


141 


Fig.    206. — Annthei-    view    of    case    shown    in    Fig.    205.      Patient   cannot    extend    arm 
beyond  position  shown  here.      Note  waist-drop,   contracture  and  atrophy. 


Fig.    207. — Another    view    of    case    shown   in    Figs.    20.5    and    206. 


142 


FRACTrRES   -VXD    DIl^LOCATIONS 


Fi".   208. A    rare    cnse    vhich    demonstrates    two    deformities    in    the    same    patient. 

Both  arms'  were  broken  some  years  ago  ,iust  above  the  elbow  and  both  elbow  joints  were 
involved  After  union  had  taken  place  the  deformities  were  recognized.  Valgus  in  one 
elbow  and  varus  in  the  opposite.  The  left  arm  shows  exaggerated  carrying  angle  while 
the  right  arm  shows  "gun-stock"  deformity.  Case  first  seen  by  author  at  the  time  this 
picture  was  taken.     Function  in   both   arms  fair  considering  the  deformities. 


Fig.  209. — Picture  taken  to  show  how  pronounced  the  normal  carrying  angle  may 
be  and  the  necessity  of  always  examining  the  opposite  eXhow.  (Left  elbow  has  been 
painted  with  iodine  following  sprain.) 


FRACTURES    OF    LOWER   END    OF    TTUMERtlS  143 

The  reflexes  and  condition  of  the  circulation  below  the  level  of 
the  fracture  should  be  tested  both  before  and  after  reduction.  The 
ulnar  nerve  is  the  structure  most  commonly  injured,  especially  in 
fractures  of  the  internal  condyle,  and  its  function  shoidd  be  most 
carefully  tested. 

The  value  of  the  X-ray  cannot  be  overestimated  in  the  diagnosis 
of  fractures  of  the  lower  end  of  the  humerus  and  should  be  made 
use  of  whenever  possible.  The  plates  taken  should  be  at  right 
angles  to  each  other  or  else  made  stereoscopically. 

Treatment. — An  accurate  appreciation  of  the  nature  of  the 
fracture  is  essential  to  the  intelligent  treatment  of  fractures  of  the 
lower  end  of  the  humerus.  As  a  rule  anesthesia  should  be  employed 
in  reducing  the  displacement  and  in  fixing  the  arm.  Reduction  is 
easily  accomplished  in  many  cases,  yet  it  is  not  uncommon  to 
encounter  a  condition  in  which  reduction  and  fixation  can  be  had 
only  with  open  treatment.  Transverse  fractures  can  usually  be 
reduced  by  grasping  the  lower  end  of  the  arm  above  the  elbow  to 
steady  the  humerus,  and  then  making  traction  in  the  axis  of  the 
semiflexed  forearm.  This  pulls  the  bones  of  the  forearm  forward 
and  with  them  the  lower  fragment  seated  in  the  sigmoid  cavity  of 
the  ulna.  AVlien  the  fragment  has  been  brought  back  into  position 
the  elbow  is  flexed  and  immobilized  in  this  position.  Treatment  of 
these  fractures  in  acute  flexion  will  give  the  best  results  in  the 
greatest  number  of  cases,  yet  the  value  of  this  position  should  not 
be  overestimated  nor  should  it  be  employed  blindly.  The  best 
position  in  v^^hich  to  treat  fractures  of  this  region  is  the  position 
which  will  most  accurately  and  securely  maintain  reduction,  and 
just  which  position  this  is  must  be  determined  in  each  and  every 
case  to  the  satisfaction  of  the  surgeon.  Much  has  been  said  and 
M^ritten  of  the  value  of  the  three  bony  prominences  in  the  diagnosis 
of  fractures  about  the  elbow,  yet  their  chief  value  lies  in  the  treat- 
ment of  these  conditions  and  seems  to  have  been  overlooked.  A 
careful  consideration  of  these  three  points  with  the  elbow  flexed 
will  enable  the  surgeon  to  determine  the  position  the  forearm  will 
occupy  when  extended.  This  determination  is  made  in  much  the 
same  manner  as  one  would  foretell  the  position  a  door  would 
occupy  when  open,  by  a  study  of  the  position  of  the  hinges  when 
closed.  This  point  is  well  illustrated  in  Figs.  202  and  203.  In 
reducing  a  fracture  in  this  region  the  surgeon  should  have  the  two 
condyles  directly  under  his  touch,  so  that  he  may  follow  the  effect 


144  FRACTURES   AND   DISLOCATIONS 

on  the  fragments  as  the  forearm  is  slowly  carried  through  flexion 
and  extension.  Tlie  degree  of  flexion  in  which  the  fragments  seem 
to  occupy  a  position  nearest  to  normal  should  be  maintained,  and 
dressings  then  applied  which  will  immobilize  the  elbow.  The  two 
condyles  should  be  in  a  line  at  right  angles  to  the  axis  of  the  shaft 
of  the  humerus,  and  neither  should  occupy  a  position  anterior  to 
the  other  (taking  the  posterior  surface  of  the  humerus  as  a  base). 
The  tip  of  the  olecranon  should  be  at  about  the  same  level  as  the 
condyles  if  extension  is  complete,  at  the  apex  of  an  equilateral 
triangle  in  acute  flexion  and  proportionately  sitiiated  between  these 
two  points  in  the  various  degrees  of  flexion.  It  will  usually  be 
found  that  posterior  displacement  of  the  lower  fragment  is  cor- 
rected, more  or  less  completely,  by  acute  flexion,  and  we  therefore 
seldom  find  the  extended  position  available  in  the  treatment  of 
these  cases.  An  arm  may  appear  well  reduced  in  the  flexed 
position,  and  the  surgeon  may  be  pleased  with  the  outlook  of  the 
case,  and  yet  after  union  has  taken  place,  the  splints  removed  and 
the  arm  extended,  a  condition  such  as  shown  in  Fig.  203  may  become 
evident,  to  the  chagrin  of  the  surgeon  and  the  dissatisfaction  of  the 
patient.  Such  results  might  be  avoided  by  a  careful  examination 
of  the  three  bony  prominences  following  reduction  as  described 
above. 

In  the  treatment  of  vertical  fractures  involving  the  articular 
surfaces  similar  principles  are  to  be  followed  out.  Acute  flexion, 
however,  is  not  nearly  as  efficient  in  preventing  recurrence  of  de- 
formity in  these  vertical  fractures  as  it  is  when  the  break  is  trans- 
verse. During  reduction  lateral  pressure  should  be  made  on  the 
fragments  in  order  that  they  may  be  forced  closer  together.  Meas- 
urements of  the  distance  between  the  two  condyles  should  be  made 
following  reduction  and  compared  wath  the  opposite  elbow.  In 
some  instances  a  detached  condyle  may  follow  the  movements  of 
the  forearm  during  flexion  and  extension,  and  when  this  occurs  the 
elbow  should  be  fixed  in  the  degree  of  flexion  in  which  the  fragment 
occupies  a  position  nearest  to  normal.  If  the  fragment  is  rotated 
it  may  be  necessary  to  operate  to  effect  reduction.  It  should  be 
remembered  that  the  displacing  action  of  the  muscles  of  the  fore- 
arm attached  to  the  condyles  varies  witli  the  degree  of  flexion  of 
the  elbow.  In  acute  flexion  the  pull  is  upward  and  forward,  in 
semiflexion  it  is  forward,  while  in  complete  extension  it  is  down- 
ward. 


FRACTURES   OF    LOWER   END    OF    HUMERUS  145 

The  principles  involved  in  the  treatment  of  epiphyseal  separa- 
tions are  the  same  as  those  given  in  the  treatment  of  fractures  of 
the  corresponding  parts. 

Special  padding  of  the  splint  may  be  of  aid  in  retaining  the  frag- 
ments though  it  is  not  so  satisfactory  a  method  as  might  be 
desired.  Displacement  depends  somewhat  on  the  extent  to  which 
the  intermuscular  septa  and  fascial  have  been  torn,  and  accordingly 
we  experience  less  difficulty  in  those  cases  in  which  the  damage 
sustained  by  these  tissues  has  been  slight. 


Fig.  210. — Method  of  fixing  the  arm  iu  a  position  short  of  acute  flexion  for  the 
treatment  of  certain  fractures  at  the  elbow.  This  method  is  far  better  than  passing 
adhesive  about  the  wrist  and  upper  part  of  the  arm  as  is  commonly  done. 

Fractures  entering  the  articular  surfaces  demand  the  most  accu- 
rate reduction.  Perfect  apposition  means  a  small  callus  and  is 
essential  to  restoration  of  joint  function. 

The  dressings  employed  to  fix  the  part  vary  with  the  degree  of 
flexion  in  which  the  elbow  is  immobilized.  In  cases  in  which  the 
traumatic  reaction  is  pronounced  it  is  advisable  to  delay  the  appli- 
cation of  dressings  until  it  has  subsided.  During  this  time  the 
patient  should  be  in  bed,  the  injured  arm  supported  on  a  pillow  and 
the  ice  cap  applied  at  intervals. 

If  the  position   of  acute  flexion  is  to  be   employed  layei*s   of 


146 


FRACTURES   AND   DISLUCATIONS 


gauze  slioiild  bo  placed  in  the  bend  of  tlie  elbow,  and  in  the  axilla, 
to  absoi-b  the  secretions  and  prevent  ehating  of  the  skin.     The  inner 


Fis.    211.  Fig.    212. 

Fig.  211. — Internal  right  angle   Dupuy  splint. 
Fig.   212. — External  right  angle  Dupuy  splint. 

surface  of  the  arm  and  forearm  should  be  prevented  from  coming 
in  contact  with  the  chest  for  the  same  reasons.  This  is  accomplished 
by  layers  of  gauze   appropriately   placed.     The  usual   method   of 


Fig.    214. 

Fig.  213. — Internal,  right-angle  splint  padded  and  secured  in  position  with  four 
strips  of  adhesive  plaster. 

Fig.  214. — Method  of  securing  traction  with  right-angli'  s])lint  and  weight.  Seldom 
advisable.      (See  text.) 

maintaining  acute  flexion  by  means  of  a  strip  of  adhesive  binding 
the  wrist  to  the  upper  part  of  the  arm,  is  mechanically  cumber- 


FRACTURES   OF    LOWER   END    OP    irUMERTJR  147 

some  and  productive  of  discomfort.  The  most  satisfactory  method 
of  securing  the  upper  extremity  in  this  position  is  shown  in  Fig. 
210.  A  strip  of  adhesive  encircles  the  wrist  and  passes  over  the 
shoulder  of  the  same  side.  In  this  way  any  position  from  semi- 
flexion to  the  most  acute  flexion  may  be  had,  and  the  amount  of 
flexion  may  be  increased  from  time  to  time  during  the  subsidence 
of  the  swelling  with  the  least  possible  disturbance  of  the  elbow.  If 
additional  security  is  desired  the  axillary  pad  may  be  employed  as 
described  in  the  "Treatment  of  Fractures  of  the  Upper  End  of 
the  Humerus"  on  page  99.  A  body  swathe  may  be  used  to  secure 
the  arm  to  the  side. 


Pig.   215. — Plaster  splints   applied  to   upper  extremity   and  held  in   position  by  straps 
of   adhesive  plaster. 

If  a  position  of  semiflexion  is  chosen  in  which  to  immobilize  the 
elbow  the  ordinary  right  angle  splint  may  be  employed.  Either 
an  internal  or  an  external  right  angle  splint  will  accomplish  the 
purpose,  though  the  former  is  usually  preferable.  This  splint 
should  be  secured  to  the  arm  first  by  strips  of  adhesive,  and  then 
fastened  to  the  forearm  while  traction  is  being  made  on  the  wrist 
to  draw  the  fragment  forward. 

When  it  is  necessary  to  immobilize  the  forearm  in  positions 
between  complete  extension  and  semiflexion,  plaster  splints  will 
usually  be  found  most  satisfactory  (see  Fig.  215). 


148  FRACTURES   AND   DISLOCATIONS 

Any  form  of  splint  applied  to  the  upper  extremity  should  be 
well  padded  with  sheet  eotton,  and  the  ent-ircliii';  bandages  or  strips 
of  adhesive  used  to  secure  it  in  position  should  not  be  so  tightly 
applied  as  to  "cause  constriction  of  the  member.  This  precaution 
is  of  the  greatest  importance  during  the  onset  of  swelling  and  if 
not  observed  may  result  in  great  damage.  A  dressing  may  fit 
properly  at  the  time  of  application  and  yet  a  few  hours  later  may 
be  causing  serious  constriction.  After  the  height  of  the  traumatic 
reaction  lias  passed  ;ni(l  the  size  of  the  arm  and  forearm  is  dimin- 
ishing, snug  ban(higing  will  often  accomplish  mnch  in  reducing 
the  swelling. 


Fig.    216. 


Fig.   217. 

Figs.    216   and   217. — Two   types  of   adjustal)le   splints   for  use   in   fractures   about  the 
elbow. 

Operative  Treatment. — The  open  method  is  productive  of  the 
best  results  in  many  cases  and  we  should  not  hesitate  to  resort  to  it 
when  the  proper  surgical  facilities  are  available  and  the  ordinary 
methods  are  not  efficient.  No  surgeon  should  operate  on  the  lower 
end  of  the  humerus  without  having  well  in  mind  the  details  of  the 
anatomy  of  the  region.  The  bone  is  peculiarly  shaped,  and  without 
an  accurate  knowledge  of  its  formation  and  the  structures  surround- 
ing it,  the  surgeon  may  do  more  harm  than  good.  There  is  con- 
siderable compact  tissue  in  the  region  of  the  condyles  and  above 
them  in  the  shaft,  but  the  bony  structure  supporting  the  articular 
surfaces  is  altogether  cancellous.  In  order  to  acquire  a  good  appre- 
ciation of  the  internal  structure  of  the  bone  it  will  more  than  repay 
the  student  to  open  a  humerus  in  coronal  and  sagittal  section,  using 
an  ordinary  hack-saw  for  the  purpose,  after  which  he  may  study 
the  nature  of  the  bone  structure  with  which  he  has  to  work.  In 
placing  wire  or  nails  we  should  rely  as  much  as  possible  on  the 
compact  tissue;  a  knowledge  of  its  disposition  and  density  will  be  of 
the  greatest  value. 

It  is  better  to  approach  the  fragments  through  an  internal  longi- 
tudinal incision  or  an  external  longitudinal  incision  or  both,  and 


FRACTURES   OF   LOWER   END    OP    HUMERUS 


149 


to  avoid,  as  much  as  possible,  injury  to  the  soft  tissu(?s  about  the 
joint.  In  this  regard  it  slionid  be  rernetnbercid  tliat  the  museulo- 
spiral  nerve  and  its  brandies  descend  o))li(jiiely  between  the 
supinator  longus  and  the  brachialis  antieus  on  tlie  outer  side  of  the 
elbow,  and  that  the  ulnar  nerve  follows  an  almost  vertical  course 
and  passes  directly  behind  the  prominent  internal  epiconclyle.  The 
external  incision  is  best  made  behind  the  musculo-spiral,  and  the 
internal  incision  slightly  anterior  to  the  ulnar  nerve  and  posterior 


Fig.    218. 


Fig.   219. 


Fig.  218. — Vertical  fracture  of  lower  end  of  humerus.  Capitellum  iucluded  in  frag- 
ment which  is  displaced  downward  and  rotated.  When  au  attempt  is  made  to  flex  arm 
the  edge  of  the  fragment  threatens  to  penetrate  the  skin.  Fragment  nailed  in  position 
at  operation   and   fracture  treated   in   a   position   of   semiflexion.      X-ray   by   H.    G.    Stover. 

Fig.  219. — Same  case  five  years  later  showing  nail  in  place,  fragment  in  reduction 
and  carrying  angle  restored.  Note  the  callus  at  upper  end  of  fracture.  Nail  has  not 
loosened  and  bony  tissue  next  to  nail  shows  no  changes.  Restoration  of  function  com- 
plete.     Injured  member  as  useful  and  strong  as  opisosite  arm.      X-ray  by   S.   B.   Childs. 

to  the  brachial  artery  and  median  nerve.  If  the  elbow  is  ap- 
proached through  either  of  the  above  incisions  the  median  nerve 
will  not  be  in  the  field  of  operation. 

After  the  bone  has  been  exposed  an  analysis  of  the  line  or  lines 
of  fracture  should  be  made,  together  with  a  consideration  of  the 
forces  preventing  reduction.  The  points  of  advantage  for  the 
placing  of  fixation  materials  are  determined  and  the  fragments 
reduced.  A  single  nail  will  sometimes  accomplish  all  that  is  re- 
quired (see  Fig.  219),  while  in  other  cases  it  will  tax  the  ingenuity 


150 


FRACTl'RES   AND    DISI.orATIOXS 


of  tlie  most  capable  to  secure  the  fi-agniciits.  A  T-fracture  may 
sometimes  be  securely  held  by  a  througli  and  tlirough  wire,  while 
in  other  instances  a  circular  wire  may  be  made  to  hind  two  or  more 
fragments  togetiier.  In  comiuinuted  conditions  it  may  be  possible 
to  secure  one  or  more  large  fragments  to  the  shaft,  or  to  bind  the 
fragments  of  the  lower  end  of  the  bone  together  by  a  wire  above  the 
condyles,  and  then  accomplish  the  balance  of  reduction  by  acute 
flexion.     Wiiile  the  bone  is  exposed  the  elbow  should  be  carried 


Figs.  220  and  221. — Same  ease  as  seen  in  Figs.  218  and  219  showing  range  of 
motion  at  elbows  and  normal  carrying  angle.  Note  the  noi-mal  relations  of  the  three 
bony  prominences  when  the  elbows  are  fully  flexed. 


through  flexion  and  extension  to  determine  the  position  which  tends 
least  to  displace  the  fragments,  and  this  position  should  be  main- 
tained in  the  after-treatment.  Care  should  be  taken  not  to  enter 
either  the  olecranon  or  coronoid  fossa  with  nail  or  wire,  as  this  may 
be  an  obstacle  to  flexion  or  extension  after  recovery.  Provision 
for  the  escape  of  blood  and  exudates  should  be  made  by  leaving  a 
small  drain  of  silk  worm  gut,  which  is  to  be  removed  in  from 
tweutv-four  to  fortv-eight  hours. 


FRACTURES    OV    LOWER    END    OF    HUMERUS  151 

The  lower  end  of  the  liunierus  not  infrequently  presents  conditions 
of  fracture  as  difiicult  to  handle  as  any  other  bone  in  the  body. 

After-Treatment. — During  the  early  part  of  the  after-treatment 
the  arm  should  be  most  carefully  watched  to  avoid  constriction. 
The  dressings  should  be  inspected  at  least  daily  to  see  that  they 
remain  in  proper  position.  The  axilla  and  bend  of  the  elbow  are 
points  likely  to  show  irritation  of  the  skin  and  require  special 
attention.  If  a  posterior  splint  is  employed  the  point  of  the  elbow 
may  need  special  padding  to  avoid  undue  pressure.  If  acute 
flexion  is  the  position  holding  the  fragments  in  reduction  it  should 
be  increased  as  the  swelling  subsides  and  the  danger  of  constriction 
grows  less. 

The  production  and  ossification  of  the  callus  is  rapid  about  the 
elbow,  and  passive  motion  and  massage  should  be  begun  at  the 
earliest  possible  moment  consistent  with  immobilization  of  the  frag- 
ments. Gentle  massage  may  be  begun  soon  after  the  subsidence  of 
the  traumatic  reaction  provided  care  is  taken  to  avoid  disturbing 
the  fragments.  Gentle  passive  motion  may  be  instituted  in  most 
cases  at  the  end  of  from  three  to  five  weeks  according  to  the  age  of 
the  patient.  Certain  cautions  should  be  noted,  however,  as  much 
harm  may  be  done  by  injudicious  motion.  The  movements  should 
be  most  guarded  and  gentle  when  first  begun,  and  the  condyles 
should  be  under  touch  of  the  surgeon  to  see  that  movement  of  the 
lower  fragment  is  not  produced.  Motion  should  in  no  case  be 
carried  far  enough  to  produce  pain,  which  may  be  taken  as  an  indi- 
cation that  more  harm  than  good  is  being  done.  Many  surgeons 
prefer  to  delay  passive  motion  until  union  is  firm  (four  to  six 
weeks  or  even  later)  and  then  if  necessary  the  adhesions  of  the  joint 
may  be  broken  up  under  anesthesia.  In  some  cases  it  will  be  neces- 
sary to  anesthetize  the  patient  a  number  of  times,  at  intervals  of  a 
week  or  ten  days,  to  keep  the  joint  surfaces  free  until  they  are 
thoroughly  healed.  During  the  intervals  the  elbow  is  immobilized 
to  allow  the  accompanying  traumatic  inflammation  to  subside. 
Such  a  procedure  is  tedious  to  both  patient  and  surgeon  but  the 
subsequent  results  usually  more  than  compensate  for  the  additional 
trouble. 

The  arm  should  be  watched  most  carefully  during  the  first  ten 
days  to  avoid  constriction  on  the  one  hand  and  loosening  of  the 
splints  on  the  other.  Strangulation  of  the  limb  is  more  likely  to 
occur  when  the  arm  is  maintained  in  a  position  of  acute  flexion, 


152  FRACTURES   AND   DISLOCATIONS 

wliilc  sli])])iner  of  llio  splints  is  most  often  seen  in  positions  between 
senii-tlexion  aiul  extension.  An  arm  slioukl  never  be  bandaged  in  a 
more  or  less  extended  position  and  tben  tiexed,  as  constriction  at  the 
elbow  is  sure  to  take  place.  The  plaster  east  is  a  most  dangerous 
dressing,  especially  if  employed  in  the  early  part  of  the  after- 
treatment.  Its  rigidity  does  not  allow  for  the  swelling  of  the  niein- 
ber  and  may  be  followed  by  damaging  constriction  and  Volkmann's 
contracture.  When  the  internal  or  external  angular  splint  is  used 
it  should  be  fixed  with  adhesive  plaster  in  at  least  three  places  as 
shown  in  Fig.  214.  If  doubt  exist  as  to  the  progress  of  union  an 
X-ray  plate  should  be  taken.  If  the  callus  is  heavy  enough  to 
throw  a  shadow  it  will  usually  be  safe  to  employ  passive  motion. 

The  removal  of  the  splints  or  dressings  should  be  gradual ;  that 
is,  they  should  be  removed  for  an  hour  or  two  each  day,  gradually 
increasing  the  time  until  they  are  permanently  removed  at  the 
end  of  a  week.  A  sling  should  be  used  for  some  time  following 
removal  of  the  splints.  Exercise  is  to  be  gradually  instituted, 
taking  as  a  guide  the  fatigue  produced.  There  should  be  no  sense 
of  fatigue  after  half  to  three  quarters  of  an  hour  following  exercise. 
It  should  be  remembered  that  the  most  valuable  and  useful  part  of 
the  function  of  the  elbow  joint  lies  in  the  range  of  motion  included 
between  acute  flexion  and  semi-flexion. 

Prognosis. — The  prognosis  in  fractures  of  the  lower  end  of  the 
humerus  varies  with,  the  age  of  the  patient,  the  severity  of  the 
lesion  and  whether  or  not  the  fracture  enters  the  joint.  Loss  of 
motion  in  the  elbow  has  been  an  unfortunately  common  sequel  to 
fractures  in  this  region,  but  with  the  advent  of  improved  treatment, 
especiall}'  the  open  method,  the  number  of  cases  of  stiff  elbow  is 
being  materially  reduced.  If  the  usual  case  of  fracture  of  the  lower 
end  of  the  humerus  is  treated  by  the  open  method,  the  fragments 
accuratelj^  reduced,  internal  fixation  employed  and  early  passive 
motion  instituted,  the  result  will  almost  invariably  be  a  functionally 
perfect  joint  without  deformity.  The  prognosis  is  of  course  equally 
good  in  cases  in  M'hich  accurate  reduction  can  be  accomplished  with- 
out operation,  but  the  X-ray  is  continually  demonstrating  the  fact 
that  these  cases  are  less  numerous  than  was  formerly  supposed. 

Surprisingly  good  function  often  follows  these  fractures  in 
children,  even  when  deformity  and  non-union  are  present.  Dis- 
turbances in  the  longitudinal  growth  of  the  bone  in  epiphyseal  sep- 
arations are  very  unusual,  being  seen  onlj^  in  instances  in  which  a 


FBACTTTRER    OF    I/)WER   END    OP    ITTJMERUS  153 

portion  or  part  of  the  epiphysis  is  widely  separated  from  the 
diaphysis.  The  bad  prognosis  so  frequently  given  in  text-books  is 
based  on  the  frequency  of  incomplete  reduction  and  the  common 
practice  of  prolonged  immobilization. 

For  the  surgeon 's  protection,  however,  he  should  be  quite  guarded 
in  the  forecast  given  the  patient  or  his  family  even  when  the  case 
is  uncomplicated.  One  never  knows  what  complications  may  arise 
during  the  course  of  the  case,  and  it  has  not  uncommonly  happened 
that  the  surgeon  found  that  he  had  to  deal  with  the  exceptional 
case  after  a  most  favorable  prognosis  had  been  given.  The  outlook 
in  compound  cases  is  of  course  worse,  yet  if  the  principles  laid  down 
in  the  chapter  on  "The  Treatment  of  Compound  Fractures"  (page 
789)  are  followed  out  a  large  percentage  of  these  open  cases  may  be 
made  to  result  as  favorably  as  simple  fractures  in  this  region. 

The  unfavorable  results  following  fractures  of  the  lower  end  of  the 
humerus  are :  Volkmann  's  contracture,  flail-elbow  resulting  from 
non-union ;  cubitus  varus,  cubitus  valgus,  backward  displacement  of 
the  lower  fragment,  and  loss  of  motion  varying  in  different  cases 
from  a  solid  ankylosis  to  a  slight  restriction  of  either  complete  flexion 
or  extension.  Volkmann 's  contracture  is  a  most  disabling  condition 
notwithstanding  the  fact  that  some  improvement  may  follow  opera- 
tion to  liberate  the  nerves.  This  complication  will  not  develop  unless 
the  arm  has  been  unduly  constricted  by  the  dressings  during  the 
after-treatment.  A  flail-elbow  will  not  follow  if  accurate  reduction 
has  been  accomplished  and,  when  present,  may  be  corrected  by  a 
secondary  operation.  Cubitus  varus  and  valgus  are  not  as  a  rule 
productive  of  much  disability.  AVhen  pronounced,  however,  they 
may  materially  weaken  the  elbow  and  render  the  patient  conspicuous 
on  account  of  the  deformity.  Complete  loss  of  motion  in  the  elbow 
is  rare.  Loss  of  complete  extension  or  acute  flexion  is  common, 
though  the  disturbance  in  function  is  Usually  so  slight  as  to  be  un- 
noticed by  the  patient.  Sixty  degrees  of  motion  at  the  elbow  will 
give  the  patient  a  serviceable  joint  even  though  the  action  is  much 
less  than  the  normal  range  of  motion.  The  sooner  the  fracture  is 
reduced  the  less  marked  will  be  the  traumatic  reaction. 

In  compound  suppurating  cases  the  outlook  is  of  course  gloomy, 
especially  when  the  fracture  enters  the  joint  cavity,  yet  it  should 
not  be  forgotten  that  union  may  be  obtained  even  in  the  presence 
of  pus  if  free  drainage  is  provided  for.  Much  may  be  done  in 
ankylosis  by  arthroclasia  and  arthroplasty. 


CHAPTER  X. 

DISLOCATIONS  OF  TIIK   ELBOW. 

I'lidcf  tills  lieading  ar<'  iiicliidcd  only  tli(  lit.\;i1  ions  in  wiiieli  botli 
bones  of  the  foreann  are  displaeed  on  the  humerus.  Ijuxations  of 
eitlier  the  ulna,  or  radius  alone  will  be  taken  up  later. 

Surgical  Anatomy. — jMueli  that  has  been  stated  under  the  head- 
ing- of  "Surgical  Anatomy"  in  "Fractures  of  the  Lower  End  of 
the  Humerus''  applies  equally  well  in  dislocations  of  the  elbow  (see 
page  120). 

The  bones  entering  into  the  formation  of  the  elbow  joint  are  the 
humerus  above,  and  the  radius  and  ulna  below.     The  articulation 


Fi2.  222. — Ligaments  of  elbow  from  radial  side.  //.,  Humerus;  R.,  Radius;  U., 
Ulna:    O.L.,   Olecranon;    E.L.,   E.xternal   lateral   ligament;    O.,   Orbicular   ligament. 

Fig.  223. — Another  view  of  the  elbow.  T.,  Tuberosity  of  radius;  O.L.,  Oblique 
ligament;    O.,   Orbicular   ligament. 

between  the  humerus  and  ulna  is  of  the  ginglymus  or  hinge  type. 
The  articulation  between  the  humerus  and  the  head  of  the  radius  is 
of  the  ball-and-socket  type,  though  the  attachments  existing  between 
the  bones  of  the  forarm  necessitate  the  radius  following  the  ulna  in 
flexion  and  extension  of  the  forearm.  The  strength  of  the  elbow, 
especially  its  lateral  stability,  depends  on  the  humero-ulnar  articu- 

154 


DISLOCATIONS   OF   THE   ELBOW  155 

lation  and  the  lateral  ligaments  of  the  elbow.  The  internal  lateral 
ligament  consists  of  two  divergent  bands  arising  from  the  epiti-ocli- 
lea;  the  anterior  band  is  attached  to  the  inner  side  of  tlie  coronoid 
and  the  posterior  band  to  the  inner  side  of  the  olecranon,  posteriorly. 
The  external  lateral  ligament  is  similar  to  the  internal ;  it  is  com- 
posed of  two  bands  arising  from  the  epieondyle.  The  anterior  band 
passes  downward  and  forward,  blends  with  the  orbicular  ligament 
and  is  attached  just  in  front  of  the  lesser  sigmoid  cavity  of  the  ulna. 
The  posterior  band  blends  with  the  orbicular  ligament,  passes  behind 
the  head  of  the  radius  and  is  attached  behind  the  lesser  sigmoid  ca  v- 
ity.  Extension  of  the  elbow  is  limited  by  the  anterior  i)ortion  of 
the  capsule,  by  the  anterior  bands  of  the  lateral  ligaments,  by  the  tip 
of  the  olecranon  coming  in  contact  with  the  bottom  of  the  olecranon 
fossa,  and  by  the  tension  of  the  biceps  and  brachialis  anticus. 
Flexion  is  limited  by  the  arm  coming  in  contact  with  the  forearm, 
by  tension  on  the  posterior  bands  of  the  lateral  ligament,  and  by 
seating  of  the  coronoid  process  in  the  fossa  of  the  same  name.  In 
the  usual  dislocation  of  the  elbow  the  orbicular  ligament  remains 
intact  and  the  radius  is  displaced  with  the  ulna.  The  overwhelming 
majority  of  luxations  of  the  elbow  are  of  the  backward  type  and  are 
usually  produced  by  forced  hyperextension  of  the  joint.  If  the 
ligaments  prove  stronger  than  the  lower  end  of  the  humerus,  frac- 
ture is  the  result ;  if  not,  luxation  of  the  elbow  is  produced. 

The  bones  of  the  forearm  may  be  displaced  in  any  direction,  and 
accordingly  the  luxations  occurring  at  the  elbow  have  been  classified 
as  follows: 

Backward  (common). 

Outward   (next  in  order  of  frequency). 

Inward  (rare). 

Forward   (rare). 

Divergent,  antero-posteriorly  (very  rare). 

Divergent,  laterally  (very  rare). 

Dislocation  of  the  bones  of  the  forearm  from  the  humerus  must 
of  necessity  be  accompanied  by  extensive  ligamentary  tearing;  the 
lateral  ligaments  being  the  ones  usually  suffering  most  extensive 
laceration.  It  not  infrequently  happens  that  a  given  ligament  is 
stronger  than  the  bone  to  which  it  is  attached,  and  accordingly  frac- 
ture is  not  an  uncommon  complication  of  dislocations  of  the  elbow. 
The  external  condyle  may  be  broken  off  and  the  fragment  remain 


156  FRACTURES   AND    DISLOCATIONS 

attached  to  and  displaced  witli  the  radius.  'I'he  cpitroclilea  is  even 
more  eonimonly  avulsed  and  displaced  by  the  action  of  the  internal 
lateral  ligament,  and  the  detached  fragment  may  act  as  an  obstacle 
to  reduction  by  becoming  interposed  between  the  trochlea  and 
sigmoid  cavity.  The  ])ei'iosteum  is  probably  always  more  or  less 
stripped  up  from  the  posterior  surface  of  the  humerus,  the  pull 
being  transmitted  through  the  posterior  ligament.  When  the  liga- 
ment proves  stronger  than  the  bone  the  olecranon  process  may  be 
fractured.  This  stripping  wp  of  the  periosteum  accounts  for  the 
deposit  of  bony  tissue  seen  on  the  posterior  surface  of  the  humerus 
following  backward  luxations.  Fracture  of  the  radial  head  or  neck 
may  occur  as  a  complication  in  luxations  of  the  elbow,  and  fracture 
of  the  shaft  or  lower  end  of  the  bone  has  been  noted.  Probably  the 
most  connnon  fracture  occurring  in  dislocations  of  this  joint  is  that 
of  the  eoronoid.  This  process  is  broken  off  as  the  ulna  is  driven 
backward  across  the  trochlea.  The  braehialis  anticus  is  attached  to 
the  anterior  surface  of  the  eoronoid,  and  when  the  fragment  is 
displaced  upward  it  is  usually  tilted  so  the  anterior  surface  looks 
more  nearly  in  an  upward  direction.  Instances  of  this  complicating 
fracture  are  shown  in  Figs.  240  to  24-1:. 

Injuries  to  vessels  and  nerves  are  fortunately  seldom  seen  except 
in  the  most  severe  compound  luxations.  The  median  and  musculo- 
spiral  nerves  are  known  to  have  been  injured  by  the  lower  end 
of  the  humerus  projecting  into  the  bend  of  the  elbow  anteriorly. 
The  ulnar  nerve  may  be  injured  as  it  passes  behind  the  epitroehlea, 
especially  when  this  process  is  fractured  or  in  the  rare  anterior 
luxation.  Cases  of  laceration  of  the  brachial  artery  are  on  record, 
but  are  extremely  rare. 

Hyperextension,  forced  abduction  or  adduction,  and  wrenches  and 
twists  of  the  forearm  are  the  types  of  violence  usually  responsible 
for  luxations  of  the  elbow. 

Symptoms. — Pain,  tenderness,  loss  of  function,  restricted  mobility 
and  swelling  of  the  parts  about  the  elbow  are  symptoms  common  to 
all  types  of  luxation  of  this  joint.  The  patient  is  unable  to  use  the 
forearm  following  injury  (usually  a  fall  on  the  outstretched  hand) 
and  complains  of  pain  which  is  greatly  increased  on  motion.  The 
elbow  is  usually  restricted  in  motion,  especially  flexion,  but  there 
may  be  some  abnormal  lateral  mobility.  There  is  no  true  crepitus 
unless  fracture  complicates  the  luxation.  The  degree  of  swelling 
is  variable  though  it  usually  appears  promptly  and  is  frequently 


DISLOCATIONS   OF    THE   ELBOW 


157 


pronounced.  The  relation  of  the  three  bony  prominences  is  dis- 
turbed (except  in  anterior  hhxation  with  fracture  of  the  ulna)  and 
on  examination  the  olecranon  will  be  found  to  be  the  displaced  ele- 
ment. The  displacement  of  the  ulna  varies  with  the  type  of  luxa- 
tion. 

The  attitude  of  the  patient  is  suggestive  of  the  Ifsioii,  though  by 


^ 

' 

^•1 

^■r 

.i^ifer*^'" 

Fig.   224. — Simple  bnokwavd  dislocation  of  elbow  a  few  minutes  after  the  accident. 


Fig.   225. — Same  case  seen  from   lieliind. 

no  means  as  characteristic  as  in  luxations  of  the  shoulder.  In  the 
posterior  luxations  the  injured  member  is  usually  allowed  to  hang 
uselessly  at  the  side,  or  is  rested  on  some  convenient  support  such 
as  a  table.  In  the  lateral  or  forward  dislocations  with  fracture,  the 
injured  arm  is,  as  a  rule,  supported  by  the  opposite  hand  and  the 
patient  is  reluctant  to  release  it  for  examination.  Deformity  is  the 
symptom  which  varies  most  in  the  different  types  of  luxation. 


158 


KHACTIRES    AM)    DISLOCATIONS 


The  posterior  variety  is  by  far  the  most  common  dislocation  at 
the  elbow,  and  is  "vvell  represented  by  the  eases  shown  in  Fiprs  224 
to  230.  The -forearm  is  usually  in  a  position  between  complete 
extension  and  semiflexion,  and  motion  in  either  direction,  beyond  a 
few  degrees,  is  painful  and  restricted  ])oth  by  spasm  of  the  muscles 
and  the  disturbed  mechanism  of  the  joint  itself.  The  olecranon  is 
raised  above  its  normal  level,  and  more  prominent  than  it  should 
be.  The  tendon  of  the  triceps  stands  out  prominently,  and  the  fore- 
arm is  shortened.     Inspection  of  the  forearm  at  the  elbow  often 


Figs.  226  and  227. — Additional  views  of  the  same  case.  Note  the  prominence  of 
the  triceps  tendon  in  the  picture  to  the  left  and  the  gun-stock  deformity  in  the  picture 
to  the  right.  This  picture  calls  attention  to  the  fact  that  gun-stock  deformity  may 
exist  in  dislocations  of  the  elbow  as  well  as  in  fractures  of  the  lower  end  of  the  humerus. 

shows  that  it  is  rotated  slightly  inward  and  displaced  outward  (see 
Fig.  230).  This  rotation  is  due  to  the  fact  that  the  inner  lip  of  the 
trochlea  pro.ieets  downward  further  than  does  the  external  lip,  and 
thus  pushes  the  ulna  to  the  radial  side,  when  the  projection  is  no 
longer  received  in  tlie  cavity  of  the  sigmoid.  The  lateral  stability 
of  the  elbow  is  not,  as  a  rule,  so  much  impaired  as  in  fractures  of 
the  lower  end  of  the  humerus.  In  palpating  the  elbow  in  backward 
dislocations,  tlie  fingers  may  be  pressed  into  the  empty  sigmoid 
cavity  of  the  ulna  and  the  thumb  may  he  placed  in  the  shallow 
depression  on  the  head  of  the  radius,  as  shown  in  Fig.  229.  The 
joint  is  painful  as  long  as  it  is  out  of  position,  yet  the  pain  is  only 
intense  when  the  elbow  is  moved.  This  displacement  is  probably 
not  as  painful  as  dislocation  of  the  shoulder.     The  coronoid  process 


DISLOCATIONS   OK    THE   ELBOW 


159 


(unless  broken  off)  rests  behind  the  trochlea,  and  if  the  elbow  is 
much  extended  it  enters  the  olecranon  fossa.  The  liead  of  the 
radius  lies  behind  the  capitellum. 


Figs.  228  and  229. — Simple  backward  dislocation  of  tlie  elbow  about  half  an  hour 
following  the  accident.  Note  the  depression  or  dimple  behind  the  elbow  which  is  char- 
acteristic of  this  condition.  Compare  this  case  with  Figs.  188,  189,  193  and  199.  Fig. 
229  shows  palpation  of  same  case.  Tlie  tip  of  the  thumb  rests  in  the  depression  on  "top 
of  the  head  of  the  radius.  The  sigmoid  cavity  of  the  ulna  lies  between  the  thumb 
and  index  finger  of  the  examining  hand  and  is  felt  to  be  empty.  The  leverage  of  the 
triceps  is  increased  while  that  of  the  biceps  is  lessened  and  hence  the  position  of  least 
pain  is  greater  than   semiflexion. 


Lateral  dislocations  of  the  elbow  may  be  divided  into  internal  and 
external.     External  lateral  dislocations  may  be  complete  or  ineom- 


160 


FRACTURES    AND    DISLOCATIONS 


l)lt'tf,  niid  lliiM-c  may  or  may  not  be  an  element  of  rotation  present, 
as  well  as  the  lateral  displacement.  The  incomplete  external  dislo- 
cation is  the  most  common  of  the  lateral  disi)lacements,  but  is  much 


Fig.  230. — In  backward  luxations  there  is  often  a  slight  displacement  of  the  ulna 
to  the  outer  side  which  can  be  best  appreciated  by  looking  at  the  elbow  from  behind. 
This  element  in  the  deformity  is  caused  by  the  inner  lip  of  the  trochlea  which  is  more 
prominent  than  the  outer.  Note  the  prominence  of  the  triceps  tendon  and  the  depres- 
sions on   either   side  of   it. 


Fig.   231. 


Fig.    232. 


Figs.  231  and  232. — Outward  dislocation  of  the  elbow.  The  upper  ends  of  the 
radius  and  ulna  have  been  displaced  outward  and  the  forearm  rotated  so  that  the  radius 
lies  above  the  ulna.  O.,  the  position  of  the  olecranon.  I.,  the  inner  edge  of  the  trochlea. 
Picture  taken  a  few  minutes  following  accident  and  the  swelling  is  only  slight. 

less  frequently  seen  than  the  backward  luxation  just  described. 
There  is  no  hard  and  fast  line  between  posterior  and  external  lateral 
dislocations,  which  point  should  be  remembered  in  dealing  Avith 


DISLOCATIONS   OP    THE   ELBOW  ]61 

luxations  of  the  elbow.  Cases  are  seen  with  backward  dislocation 
accompanied  by  an  external  displacement,  and  cases  of  external 
dislocation  are  seen  with  an  element  of  l)ackward  displacement,  and 
it  is  difficult,  in  many  cases,  to  say  which  element  of  the  condition 
is  more  prominent.  An  arbitrary  dividing-  line  is  considered  by 
some  to  be  the  position  of  the  coronoid ;  if  this  process  lies  anterior 
to  the  trochlea  the  dislocation  is  lateral,  but  if  it  lies  behind  the 
trochlea  it  is  posterior.  Such  a  division  makes  the  conditions  fit  tlie 
classification,  rather  than  the  classification  fitting  the  condition. 

The  external  lateral  dislocation  is  usually  incomplete,  the  sigmoid 
of  the  ulna  embraces  the  capitellum,  and  the  head  of  the  radius 
stands  out  externally ;  more  frequently  the  head  of  the  radius  is 
raised  above  the  level  of  the  ulna  and  lies  on,  or  close  to,  the 
epicondyle.  This  elevation  of  the  head  of  the  radius  produces  an 
inward  rotation  of  the  forearm,  and  the  condition  is  spoken  of  as 
lateral  dislocation  with  rotation  or  pronation.  In  other  instances 
we  find  a  complete  external  displacement  of  the  bones  of  the  fore- 
arm. In  such  cases  the  ulna  has  been  carried  further  outward  and 
rests  on  the  surface  of  the  epicondyle ;  the  radius  may  lie  external  to 
the  ulna  or  above  it,  and  accordingly  we  have  complete  external 
dislocation  with  or  without  rotation  or  pronation  of  the  forearm. 
The  ligaments  are  more  or  less  torn  according  to  the  degree  of  dis- 
placement, but  only  in  rare  instances  may  the  injury  to  the  liga- 
ments (especially  the  anterior  and  internal)  be  considered  slight. 
It  is  not  uncommon  to  find  the  internal  lateral  ligament  stronger 
than  the  bone  to  which  it  is  attached,  which  accounts  for  the  occa- 
sional fracture  and  outward  displacement  of  the  epitrochlea.  This 
fragment  may  act  as  an  obstacle  to  reduction  by  becoming  inter- 
posed between  the  articular  surfaces  of  the  ulna  and  humerus.  The 
elbow  will  be  found  broadened  according  to  the  degree  of  displace- 
ment. The  relation  of  the  three  bony  prominences  is  disturbed. 
The  olecranon  will  be  felt  external  to  its  normal  position  and  the 
head  of  the  radius  located  external  to  the  epicondyle.  The  internal 
condyle  is  subcutaneous  and  very  prominent,  and  the  inner  edge 
of  the  trochlea  may  be  palpated  below  it,  just  under  the  skin.  The 
epicondyle  is  not  palpable  because  of  the  external  displacement  of 
the  bones  of  the  forearm.  One  not  accustomed  to  these  conditions 
of  the  elbow  may  become  confused  in  attempting  to  identify  the 
three  bony  prominences,  and  a  diagnosis  of  fracture  in  such  eases 
is  common,  when  none  really  exists. 


162  FRACTURES   AND   DISLOCATIONS 

Infernal  lateral  elislocation  of  the  elbow  is  quite  rare  and  only 
seen  in  tlie  incomplete  variety.  The  sigmoid  of  the  ulna  embraces 
the  internal  epicondyle,  while  the  head  of  the  radius  is  displaced 
more  or  less  inwai'd  onto  the  outer  portion  of  the  trochlea.  The 
forearm  is  inclined  to  a  jiosition  of  supination,  and  the  olcci-anon  is 
out  of  relation  with  the  condyles  of  the  humerus.  Complications  in 
lateral  dislocations  are  extremeh'  rare,  and  consist  for  the  most  part 
in  fracture  of  the  internal  epicondyle;  fracture  of  the  external 
condyle  has  been  reported. 

Forward  dislocation  of  ihc  elbow  is  extremely  rare  and  seems  to 
lip  secondary  to  fracture  of  the  olecranon.  Fracture  of  this  pi-ocess, 
at  the  bottom  of  the  sigmoid  cavity,  may  result  in  the  distal  frag- 
ment of  the  ulna  being  driven  upward  in  front  of  the  humerus 
by  the  same  force  that  produced  the  fracture.  Complete  anterior 
dislocation,  without  fracture  of  the  olecranon,  is  so  rare  that  it 
had  better  be  considered  an  anomaly.  The  fractured  olecranon 
may  be  recognized  by  palpation  and  the  abnormally  high  position 
of  the  upper  part  of  the  forearm,  and  its  change  in  axis  may  be 
determined  without  difficulty  (see  Fig.  239).  When  the  olecranon 
is  not  fractured  it  either  lies  in  front  of  the  lower  end  of  the 
humerus  or  (in  the  incomplete  form)  the  end  of  the  process  rests 
on  the  trochlea,  the  lateral  ligaments  having  suffered  extensive 
laceration. 

Divergent  dislocations  of  the  elbow  are  very  rare  indeed,  being 
usually  the  result  of  great  trauma.  They  are  sometimes  seen  in 
falls  from  a  height  and  in  severe  machinery  accidents.  One  reason 
for  the  rarity  of  these  dislocations  is  that  the  arm  is  seldom  caught 
in  just  such  a  manner  as  to  tear  both  the  heavy  orbicular  ligament 
and  the  interosseous  membrane,  and  the  force  so  directed  as  to 
displace  the  bones  in  different  directions.  There  are  two  forms  of 
divergent  dislocation — antero-posterior  and  lateral.  In  the  antero- 
posterior the  radius  lies  anterior  to  the  humerus,  and  the  ulna 
behind  it.  The  posterior  aspect  of  the  elbow  resembles  quite 
closely  the  simple  posterior  variety  of  dislocation,  the  point  of 
differentiation  being  the  presence  of  the  head  of  the  radius  in  front 
of  the  elbow.  The  lateral  variety  is  so  rare  that  few  cases  have 
been  reported.  The  ulna  lies  to  the  inner  side  of  the  humerus, 
while  the  radius  is  displaced  externally,  and  the  elbow  is  accordingly 
increased  in  breadth  to  nearly  twice  that  of  normal. 

The  symptoms  produced  by  injury  to  nerves  or  vessels  will  depend 


DISLOCATIONS    OF    THE   ELBOW  163 

on  which  of  these  structures  has  been  damaged.  The  paralyses  or 
disturbances  in  circulation  are  the  same  as  follow  injury  to  the 
nerves  and  vessels  of  the  upper  extremity  from  causes  other  than 
dislocation  of  the  elbow. 


Figs.  233,  234  and  235. — Diagrams  showing  tlie  bony  relations  in  the  three  most 
common  injuries  at  the  elbow.  The  npper  diagram  is  of  a  posterior  dislocation.  Not-e 
the  empty  sigmoid  cavity.  The  middle  drawing  is  of  a  dia-condylar  fracture  while  the 
lower  is  of  a  supracond,\"lar  fracture.  There  is  no  hard  and  fast  line  between  the  supra- 
and  dia-condylar  fractures  yet  the  terms  are  used  to  indicate  the  level  of  the  break. 

Diagnosis. — The  recognition  and  differentiation  of  the  various 
types  of  luxation  of  the  elbow  are  made  on  the  symptoms  just 
described.  In  establishing  a  diagnosis  of  dislocation  of  the  elbow 
the  surgeon  must  keep  in  mind — first,  the  bony  lesions  which  are 


164 


KUACnilKS    AN'n    1)IS1,OCATIONS 


most  conimonly  niistakcii  i'or  luxation;  second,  the  complicating' 
fractures  which  sometimes  accompany  dislocations;  and  third,  the 
complicatinii;  lesions  of  the  soft  tissues,  such  as  injury  to  vessels 
and  nerves.  The  condition  most  freiiucut ly  confounded  with  dislo- 
cation is  fracture  or  epiphyseal  separation  of  the  lower  end  of  the 
humerus.  In  fracture  of  the  lower  end  of  the  humerus  with  back- 
ward displacement,  the  sigmoid  is  not  found  tiii|)ty  and  it  is 
impossible  to  feel   tlu^   ('up-sha])od  depression   on   the  head   of  the 


Fig.  236. — Case  of  simple  sprain  of  the  elbow  twenty-four  hours  after  the  acci- 
dent. Note  the  swelling  which  is  a«  great  as  is  seen  following  fracture  or  dislocation 
and  materially  interferes  with  examination  and  diagnosis.  Note,  however,  that  there  is 
no  ecchymosis  which  is  so  common  in  fractures,  after  the  first  twelve  or  twenty-four 
hours. 


radius  as  shown  in  Fig.  229.  The  backward  displacement  is  usually 
less  prominent  in  fractures,  and  the  deformity  is,  as  a  rule,  per- 
ceptibly higher.  The  relation  of  the  three  bony  prominences  is  dis- 
turbed in  vertical  fractures  of  the  lower  end  of  the  humerus,  in 
dislocations  of  the  elbow  and  in  fractures  of  the  olecranon,  but  not 
in  transverse  fractures  of  the  lower  end  of  the  humerus.  (See 
Figs.  233  to  235  and  compare  the  deformities.)  Dislocations  of 
the  upper  end  of  the  ulna  alone  are  differentiated  from  luxations 


DISIiOCATIONS    OP    TTTK    VAAiOW 


165 


of  the  elbow  by  the  position  of  the  head  of  tlie  radius  which  rcmaitis 
in  its  proper  relation  with  the  capitellum. 

To  avoid  mistakes  it  is  well  to  identify  the  ulna  at  its  lower  end 
and  trace  the  posterior  subcutaneous  border  up  to  the  olecranon; 
the  head  of  the  radius  may  next  be  identified  and  rotated  by 
supinating  and  pronating  the  forearm.  After  these  two  points  have 
been  positively  identified  there  will  usually  be  little  difficulty  in 
recognizing  the  other  landmarks  of  the  elbow.     When  the  case  is 


Fig.  237. — Case  of  lateral  dislocation  of  the  elbow  twenty-four  hours  after  injury 
and  reduction.     Note  the  swelling  about  the  elbow. 

Fig.  238. — Same  case  after  palpation  of  three  bony  prominences  and  marking  same 
with  ink. 

seen  early  a  tentative  diagnosis  can,  as  a  rule,  be  made  by  inspection 
alone,  but  if  first  seen  after  swelling  has  developed  it  may  be  quite 
difficult  to  examine  and  determine  the  condition. 

Gentle,  firm  and  continued  pressure  with  the  fingers  in  the  region 
of  the  condyles  and  olecranon  will  usually  displace  the  fluids  within 
the  tissues  sufficiently  to  allow  the  surgeon  to  determine  the 
positions  and  conditions  of  the  three  bony  prominences.  An  anes- 
thetic is  often  advisable  if  the  traumatic  reaction  is  pronounced  at 
the  time  of  the  examination.     An  even  better  procedure  under  these 


ion 


FRArTl'RES    AXD    nTSI,(  jfATIOXS 


circ'iiinstanees  (provided  the  defonuity  is  not  '^rcil  iiiul  llic  X-ray 
is  promptly  available^  is  to  le;ive  llic  pints  nudist  ui-IumI  jiikI  dctei-- 
miiie  the  natui'e  of  the  in,iiii-\-  I'l-om  ;i  litintiicnoLiiani. 


Pig.    239. — Anterior    luxation    of    the    ellmw    willi    I'rMcturr    of    llio    olccraiioii.       (SriKill 
nails  seen  in  plate  are  in   sijlint.) 


Fig.  240. — A  not  uncommon  complication  of  backward  dislocations  of  the  elbow. 
The  coronoid  process  has  been  broken  off  and  is  displaced  upward  by  the  brachialis 
anticus.  This  muscle  is  inserted  into  the  anterior  surface  as  well  as  the  tip  of  the 
process   which   accounts  for  the  tipping  of  the  fragment   as   it  is  pulled  upward. 

Fracture  of  the  coronoid  is  often  difficult  to  recognize  because 
of  the  swelling.     It  is  frequently  impossible  to  palpate  the  detached 


DISLOCATIONS   OP   THE   ELBOW 


167 


particle  of  bone,  and  the  fact  that  the  fragment  is  usually  displaced 
upward  prevents  crepitus. 

Complications  are  fortunately  rare  yet  they  do  occasionally  occur 
and  should,  if  possible,  be  recognized  before  reduction.  The 
diagnosis  of  these  conditions  is  often  made  only  after  reduction 


Fig.   241. 


Fig.   241. — Backward  luxation  fracture  of  the  tip  of  the  coronoid  process. 
Fig.  242. — Backward  hixation  with  comminuted  fracture  of  coronoid  process. 


Fig.   243 


Frac- 


Fig.   243. — Large  fragment  of  coronoid  displaced  upward  by  action  of  biceps, 
ture  result  of  backward  luxation  of  elbow. 

Fig.    244. — Fracture    of    coronoid    with    only    slight    displacement.      Result    of    back- 
ward luxation  of  elbow. 

has  been  attempted  or  accomplished,  and  many  cases  would  go  un- 
recognized if  it  were  not  for  the  X-ray.  The  condition  of  the 
reflexes  and  the  circulation  below  the  level  of  the  lesion  should  be 
determined  both  before  and  after  reduction.  Eecurrence  of  de- 
formity following  reduction  is  suggestive  of  fracture  of  the  lower 
end  of  the  humerus  or  of  the  coronoid  process  of  the  ulna. 

Treatment. — The  treatment  of  dislocations  of  the  elbow  consists 
in  returning  the  ulna  and  radius  to  their  normal  relations  with 
the  humerus,  and  immobilizing  the  elbow  for  a  period  sufficiently 
long  to  allow  complete  healing  of  the  ligaments.  The  case  should 
be  attended  as  soon  following  the  accident  as  possible.  The  longer 
the  luxation  exists  the  more  difficult  will  be  the  diagnosis,  the  more 
painful  the  parts  and  the  more  pronounced  the  secondary  traumatic 


168 


FRACTURES   AND    DISLOCATIONS 


reaction.  Reduction  of  the  dislocation  is  usually  not  difficult,  and 
according  to  the  most  coiiunoii  nictliod,  consists  (for  1)ack\vard 
luxations)  in  trai-tioii  ami  coinilci'-ti-actioii  with  liyjicr-extension 
of  the  joint  followed  by  tlexion.     Tlic  ai-iii  is  tirnily  grasped  above 


Fig.  245. — Method  of  reducing  backward  luxation  of  tin-  illi.iw.  Traction  on  tlie 
forearm  at  the  wrist  with  counter-traction  with  the  opposite  hand  on  the  arm.  A 
greater  degree  of  extension  is  often  necessary  to  help  the  coronoid  to  clear  the  trochlea. 


Fig.  240. — Another  method  of  reducing  backward  lu.xations  of  the  elbow.  The 
lower  part  of  the  arm  is  grasped  with  both  hands  as  shown  in  illustration  ^yhile  the 
thumbs  force  the  olecranon  downward  into  position.  With  the  hand  fixed  on  the  table 
any  desired  degree  of  flexion  at  the  elbow  may  be  obtained  during  the  manipulation. 

the  elbow  with  one  hand  while  the  other  makes  traction  from  the 
wrist ;  during  this  traction  the  forearm  is  somewhat  hyper-extended 
to  allow  the  coronoid  to  clear  the  trochlea,  after  which  the  forearm 
is  flexed  and  reduction  is  complete.     The  ligaments  are  usually  torn 


DISLOCATIONS    OP    THE   ELBOW  169 

to  such  an  extent  that  they  offer  little  resistance  to  reduction,  but 
the  muscles,  especially  in  well  developed  [)ersons,  may  as  a  result 
of  spasm,  render  reduction  extremely  difficult.  A  method  of  reduc- 
tion, particularly  adapted  to  children,  consists  in  forcing  the 
olecranon  into  place  with  the  thumbs  while  the  fingers  fix  the  arm 
above  the  elbow  as  shown  in  Fig.  246.  By  having  the  patient's 
hand  resting  on  a  table  flexion  and  extension  may  be  controlled  by 
raising  or  lowering  the  elbow  during  the  manipulation,  thus  helping 
the  coronoid  to  clear  the  trochlea.  Still  another  method  is  one  in 
which  the  joint  surfaces  are  separated  and  flexion  of  the  elbow 
accomplished  over  the  operator's  knee.  Keduction  may  also  be 
accomplished  by  means  of  continuous  traction  with  weights,  but  the 
first  method  described  will  be  found  as  satisfactory  as  any  in  the 
average  case  of  posterior  luxation. 

The  muscles  offer  the  chief  obstacle  to  reduction  and  accordingly 
the  use  of  an  anesthetic  will  render  difficult  cases  easy.  The  liga- 
ments are  already  much  torn  and  we  should  avoid  manipulations 
which  will  subject  them  to  further  injury ;  this  point  should  be  kept 
well  in  mind  when  using  an  anesthetic,  as  the  joint,  under  such 
conditions,  is  no  longer  protected  by  the  action  of  the  muscles. 
When  the  bones  are  displaced  outward  further  than  is  caused  by  the 
internal  lip  of  the  trochlea  (see  Figs.  231  and  232),  they  should  be 
converted  into  a  simple  backward  dislocation  before  reduction  is 
attempted.  The  less  force  used  the  better,  and  in  a  given  case  it 
is  often  preferable  to  try  different  methods  with  moderate  force, 
before  using  any  particular  one  with  much  force.  There  is  probably 
no  method,  in  backward  dislocations  of  the  elbow,  which  meets 
the  indications  as  scientifically  as  does  Kocher's  in  reduction  of 
anterior  luxations  of  the  shoulder,  yet  the  ones  in  use  are  effective 
and  though  not  ideal  are  at  least  satisfactory. 

In  reducing  an  outward  luxation  it  is  of  the  greatest  advantage 
to  have  an  assistant  fix  the  lower  end  of  the  humerus,  thus  affording 
the  surgeon  a  solid  basis  on  which  to  force  the  bones  of  the  forearm 
into  position.  Before  reduction  is  attempted  the  surgeon  should 
know  whether  or  not  rotation  is  present,  as  well  as  lateral  displace- 
ment. With  the  lower  end  of  the  arm  fixed,  traction  is  made  on  the 
wrist,  while  the  opposite  hand  grasps  the  elbow  and  forces  the 
upper  ends  of  the  radius  and  ulna  downward  and  inward  around 
the  lower  end  of  the  humerus.  If  the  bones  of  the  forearm  are  dis- 
placed backward  as  well  as  outward  it  may  be  advisable  to  accom- 


170  FRACTURES    AND    DISLOCATIONS 

plish  reduction  as  if  the  displacement  were  straight  backward,  with 
the  addition  of  hiteral  pressure  as  the  joint  surfaces  are  beinj? 
brought  together.  The  most  eonunon  obsti'uetion  to  I'eduetion  is  the 
lodgment  of  an  epitrochlear  fragment  between  the  articular  sur- 
faces. If  the  elbow  is  liyper-extended  this  fragment  can  as  a  rule 
be  gotten  out  from  l)etween  the  articuhn-  surfaces.  Downward 
traction  on  the  semiflexed  forearm  with  a  rocking  motion  will  some- 
times be  effective  in  displacing  the  fragment. 

Reduction  of  an  inivard  dislocation  is  aceom|)lish('d  in  a  manner 
similar  to  correction  of  the  outward  displacement  except  that  out- 
ward pressure  is  exerted  during  traction,  instead  of  inward  pres- 
sure. There  is  usually  little  difficulty  in  reducing  this  type  of  luxa- 
tion. 

In  forward  Iterations  with  the  usu'd  fracture  of  the  olecranon, 
reduction  is  accomplished  by  downward  pressure  on  the  upper  part 
of  the  semiflexed  forearm,  thus  forcing  the  head  of  the  radius  back 
onto  the  capitellum  and  the  ulna  back  into  alignment  with  the  frag- 
ment of  the  olecranon.  In  the  rare  instances  in  which  fracture  of 
the  olecranon  does  not  complicate  the  luxation,  reduction  is  accom- 
plished by  acutely  flexing  the  forearm,  and  then  forcing  the  tip 
of  the  olecranon  past  the  trochlea  by  downward  pressure.  In  the 
incomplete  form  of  the  dislocation,  in  which  the  olecranon  lies  on 
and  not  in  front  of  the  trochlea,  this  manipulation  is  fairly  safe, 
but  in  the  complete  form  there  is  grave  danger  of  injury  to  the 
ulnar  nerve.  To  lessen  this  danger  the  arm  should  be  adducted 
until  the  olecranon  has  passed  the  trochlea.  Complete  forward 
luxation  of  the  elbow  is  however  extremely  rare. 

In  divergent  luxations  of  the  elbow  traction  is  to  be  made  on  the 
extended  forearm  and  each  bone  reduced  separately. 

After  reducing  a  dislocation  of  the  elbow,  regardless  of  the  type, 
the  joint  should  be  carried  through  its  normal  range  of  motion  and 
the  parts  carefully  examined  so  that  complications  may  not  be  over- 
looked. 

Operative  Treatment. — Operation  is  indicated  when,  after 
repeated  trials  under  an  anesthetic,  the  joint  remains  displaced 
and  in  cases  in  which  complications  such  as  irreducible  fracture  or 
injury  to  vessels  or  nerves  exist.  The  joint  may  be  approached  by 
an  external  longitudinal  or  an  internal  longitudinal  incision,  accord- 
ing to  the  preference  of  the  surgeon  and  the  conditions  present. 
The  ulnar  nerve  lies  internal  to  the  elbow  behind  the  epitrochlea, 


DISLOCATIONS    OF    THE    KLBOW  171 

while  the  musculo-spiral  descends  behind  the  supinator  longus  as 
described  in  Operative  Treatment  of  "Fractures  of  the  Lower  End 
of  the  Humerus"  on  page  148,  and  should  be  protected  from  injury 
during  operation.  It  may  occasionally  be  necessary  to  divide  some 
of  the  ligaments  to  replace  the  bones.  The  external  condyle  may  be 
broken  off  and  displaced  backward  with  the  radius,  and  if  the  frag- 
ment cannot  be  accurately  reduced  by  manipulation  it  is  advisable 
to  secure  it  with  a  nail  or  wire.  The  internal  epicondyle  may  be 
separated,  and  when  the  fragment  becomes  wedged  between  the 
articular  surfaces  it  may  be  necessary  to  operate  to  release  it  and 
effect  reduction.  Not  infrequently  internal  fixation  is  indicated  to 
maintain  reduction  of  the  fragment  when  fracture  complicates  the 
luxation,  and  the  principles  involved  are  the  same  as  have  already 
been  described  under  the  heading  of  Operative  Treatment  of 
"Fractures  of  the  Lower  End  of  the  Humerus"  on  page  148.  Frac- 
ture of  the  coronoid  is  not  an  uncommon  complication  and  may,  as 
a  rule,  be  successfully  treated  with  the  elbow  in  the  tlexed  position. 
When,  however,  the  fragment  is  large  and  the  upward  displacement 
is  so  pronounced  as  to  prevent  approximation  by  flexion,  it  will  be 
advisable  to  operate  and  suture  the  fragment  in  position.  Suture 
of  the  ligament  and  surrounding  soft  tissues  will,  as  a  rule,  suffice 
in  holding  the  fragment  in  place. 

Complicating  fracture  of  the  head  of  the  radius  does  not  call  for 
operative  intervention  except  in  very  rare  cases. 

When  fracture  of  the  olecranon  exists  it  may  be  difficult  to  keep 
the  fragments  in  apposition  ;  open  incision  and  internal  fixation  may 
be  called  for  to  secure  proper  reduction  of  the  process.  (See  Oper- 
ative Treatment  of  "Fracture  of  the  Olecranon,"  page  191.) 

The  advisability  of  operating  for  the  correction  of  old  unreduced 
luxations  depends  almost  entirely  on  the  amount  of  function  lost. 
If  the  patient  is  enjoying  free  use  of  the  joint  and  the  elbow  is 
strong,  it  will  be  absurd  to  advise  operation  simply  to  correct  the 
deformity.  Operation  for  the  correction  of  old  displacements  is 
performed  according  to  the  same  principles,  and  the  same  precau- 
tions are  to  be  observed,  as  already  given  in  the  open  treatment  of 
recent  cases.  A  certain  amount  of  fibrous  tissue  will  usually  be 
found  within  the  sigmoid  cavity  and  should  be  removed  before  the 
luxation  is  reduced. 

After-Treatment. — The  after-treatment  consists  in  immobilizing 
the  joint  sufficiently  long  to  allow  proper  healing  of  the  ligaments. 


172 


FRACTURES   AND   DISLOCATIONS 


In  posterior  luxations  tlic  anterior  lifxament  is  most  extensively  torn 
and  the  flexed  position  will  be  the  one  which  will  bring  the  torn 
ends  nearest  together ;  the  same  holds  true  when  the  coronoid  has 
been  fractured,  therefore  the  best  position  will  be  found  to  be 
one  just  short  of  acute  tiexioji.  Complete  flexion  is  a  position  which 
is  quite  uncomfortable  and  poorly  adapted  to  the  swelling  of  the 
elbow  which  is  to  follow,  and  for  these  reasons  a  position  a  few 
degrees  short  of  complete  flexion  is  advised.  The  arm  and  forearm 
should  be  bandaged  in  this  position  and  the  axilla  protected  to 


Fig.    248. 


Figs.  247  and  248. — These  two  figures  show  the  range  of  motion  fourteen  days  after 
a  posterior  luxation  of  the  elbow.  Note  how  the  swelling  has  subsided  as  compared  with 
the  case  seen  twenty-four  hours  after  the  dislocation,   as  shown  in  Figs.   237  and  238. 

prevent  skin  coming  in  contact  with  skin,  and  some  means  of  fixa- 
tion applied  as  has  already  been  described  under  the  head  of  "Frac- 
tures of  the  Lower  End  of  the  Humerus,"  page  210.  Passive 
motion  of  the  joint  should  not  be  begun  until  the  acute  traumatic 
reaction  has  fully  subsided,  which  will  be  at  the  end  of  a  week  or 
ten  days.  This  will  allow  some  time  for  the  capsule  to  heal,  but 
immobilization  should  not  be  too  prolonged,  as  unnecessary  stiifen- 
ing  of  the  elbow  may  result.  Passive  motion  should  not  be  delayed 
longer  than  two  weeks  and  should  at  all  times  be  gentle.     When 


DISLOCATIONS   OF    THI5    ELBOW  M'A 

once  begun  it  should  be  practised  every  two  to  four  days  until 
complete  or  nearly  complete  motion  is  regained.  The  use  of  hot 
applications  and  massage  daily  will  hasten  recovery.  The  carrying 
of  weights  will  materially  increase  extension  during  the  latter  part 
of  the  after-treatment.  The  elbow  will  show  more  or  less  stiffness 
when  the  dressings  have  been  removed  and  will  remain  so  for  a 
short  time  but  this  is  no  occasion  for  anxiety  as  function  will  return 
with  passive  motion,  massage,  and  use  of  the  arm.  Complete 
extension  will  be  the  last  to  return  and  may  never  be  fully  regained 
if  the  periosteum  on  the  back- of  the  humerus  has  been  extensively 
stripped  up  and  followed  by  a  deposit  of  new  bone  under  it  in  the 
region  of  the  olecranon  fossa.  The  fixation  does  not  need  to  be 
as  absolute  as  is  maintained  in  fracture,  but  should  be  kept  up  for 
two  to  three  weeks,  and  action  requiring  much  strength  should  be 
avoided  for  another  two  to  three  weeks.  The  attitude  to  be  partic- 
ularly avoided  is  complete  extension  within  a  week  of  the  injurj^, 
and  this  should  be  the  last  position  in  which  muscular  effort  is  per- 
missible, after  the  patient  is  again  using  the  arm. 

Fixation  in  a  position  of  supination  will  tend  to  relax  the  supina- 
tors and  should  be  employed  when  complicating  fracture  of  the 
external  condyle  or  epicondyle  exists.  Flexion  and  pronation  will 
relax  the  pull  on  the  internal  condyle  and  epitrochlea  in  the 
presence  of  fracture  in  this  region. 

The  after-treatment  of  forward  dislocations  is  much  the  same  as 
has  already  been  described.  The  presence  of  complications,  such 
as  nerve  or  vessel  injury,  may  necessitate  operation.  The  ulnar 
nerve  may  be  stretched  or  torn  and  require  suture. 

The  after-treatment  of  divergent  dislocations  is  much  the  same 
as  other  dislocations  about  the  elbow.  The  joint  should  be  put  at 
rest  for  a  month  to  allow  the  ligaments  to  heal,  but  absolute  fixa- 
tion is  not  as  desirable  as  it  is  in  fracture.  It  is  well  to  fix  the 
elbow  in  a  posterior  right  angle  splint  for  the  first  ten  days  to  two 
weeks,  after  which  a  sling  may  be  used  which  supports  the  entire 
forearm.  After  the  splint  has  been  removed  gentle  passive  motion 
may  be  employed  at  intervals  of  four  or  five  days,  but  should  be 
painless.  Some  restriction  of  motion  may  follow  the  injury  and 
subsequent  immobilization,  but  this  is  better  than  a  condition  of 
recurrent  dislocation.  Accordingly,  in  view  of  the  extensive  injury 
sustained  by  the  ligaments  and  soft  tissues,  it  is  preferable  to  incline 
toward  the  safer  course  and  not  allow  motion  too  soon.     Extreme 


174  FRACTURES   AND   DISLOCATIONS 

extension  should  be  avoided  during  passive  motion  ajid  the  patient 
should  be  warned  against  strain  in  this  position  for  some  months 
following  the  accident. 

Prognosis. — The  prognosis  in  luxations  of  the  elbow  dei)ends  ou 
the  extent  of  laceration  sustained  by  the  ligaments  and  the  presence 
of  complications.  The  amount  of  damage  to  the  ligaments  is  in 
direct  proportion  to  the  extent  of  displacement.  In  simple  cases 
of  posterior  luxation  we  may  look  for  complete  restoration  of  func- 
tion if  the  after-treatment  is  properly  carried  out.  The  last  few 
degrees  of  extension  may  be  permanently  lost,  but  this  does  not 
disturb  the  usefulness  of  the  joint  and  is  negligible.  Extensive 
injury  to  the  soft  tissues  and  complicating  fracture  will,  of  course, 
render  the  prognosis  more  doubtful. 

Young  persons  make  more  rapid  and  complete  recovery,  while  on 
the  other  hand  those  advanced  in  years  (especially  with  rheumatic 
diathesis)  are  liable  to  be  troubled  with  the  joint  for  a  long  time. 
Fortunately  the  more  common  forms  of  dislocation  are  followed  by 
useful  and  strong  joints,  if  the  ligaments  are  allowed  time  to  heal. 
The  dislocations  that  are  accompanied  by  great  laceration  of  the 
ligaments  are  most  likely  to  be  followed  by  weakness  of  the  parts  or 
recurrence  of  the  displacement.  Nerve  injury  accompanying  the 
accident  may  be  followed  by  paralysis  and  anesthesia,  the  same  as 
nerve  injur^'^  from  other  causes.  Damage  to  nerves  usually  consists 
of  simple  stretching  and  is  generally  not  severe.  As  a  rule  recovery 
takes  place  within  a  few  months  at  most.  Complete  rupture  of  a 
nerve  results  in  a  permanent  paralysis  unless  operated,  and  even 
then  recovery  may  be  extremely  long  and  tedious.  The  ulnar  nerve 
is  most  frequently  involved,  the  musculo-spiral  next,  while  the 
median  nerve  rarely  suffers  injury.  Considering  the  frequency 
with  which  the  elbow  is  dislocated  injury  to  the  nerves  in  this  region 
is  rare,  and  the  ultimate  prognosis,  even  in  cases  of  complete  sever- 
ance, is  good,  if  the  divided  ends  are  brought  together  and  properly 
sutured  soon  after  the  accident. 


CHAPTER  XI. 

DISLOCATIONS  OF  THE  ULNA  ALONE   (ROTARY). 

Surgical  Anatomy. — The  surgical  anatomy  of  luxations  of  the 
upper  end  of  the  ulna  alone,  is  similar  to  that  already  given  in 
"Dislocations  of  the  Elbow"  on  page  154.  Dislocations  of  this  type 
are  quite  rare,  whereas  luxations  of  the  elbow  (both  bones)  are  by 
no  means  uncommon. 

The  upper  end  of  the  ulna  may  be  displaced  either  backward  or 
forward,  describing  the  arc  of  a  circle,  of  which  the  undisplaced 
radial  head  is  the  center.  Both  types  are  exceedingly  rare,  but  of 
the  two  the  posterior  is  the  more  common.  In  either  form  the  inter- 
osseous membrane  and  oblique  ligament  are  probably  not  torn,  and 
the  head  of  the  radius  remains  in  position  on  the  capitellum.  The 
injury  is  probably  produced  by  trauma  which  twists  the  forearm  at 
the  same  time  adducting  or  abducting  it. 

Symptoms. — The  posterior  variety  presents  a  characteristic 
clinical  picture.  The  forearm  is  more  or  less  extended  and  there 
is  a  pronounced  "gunstock  deformity."  The  olecranon  is  promi- 
nent and  raised,  though  the  displacement  is  usually  not  as  pro- 
nounced as  seen  in  posterior  luxations  of  both  bones.  The  tip  of 
the  coronoid  may  rest  on  the  trochlea,  or  behind  it,  or  the  upper  end 
of  the  bone  may  be  still  further  displaced  so  that  it  rests  behind  the 
external  condyle.  The  further  the  backward  displacement  of  the 
upper  end  of  the  ulna,  the  more  external  will  be  the  position  occu- 
pied by  the  olecranon  and  the  more  pronounced  will  be  the  cubitus 
varus.  The  epitrochlea  is  prominent  and  more  anteriorly  situated 
than  normal,  with  relation  to  the  forearm.  There  is  a  compensatory 
outward  rotation  of  the  humerus  to  accommodate  the  altered 
position  of  the  forearm.  The  internal  lateral  ligament  may  be 
ruptured  or  an  equivalent  avulsion  of  the  epitrochlea  may  exist. 

In  forward  luxations  the  ligamentary  laceration,  especially  on 
the  inner  side  of  the  elbow,  is  greater  and  the  causative  trauma  is 
more  severe.  The  forearm  may  lie  anywhere  between  semiflexion 
and  complete  extension.     There  is  abnormal  lateral  mobility  in  the 

175 


176  FRACTURES   AND    DISLOCATIONS 

direction  of  abduction.  The  top  of  the  olecranon  lies  either  on,  or 
in  front  of,  the  trochlea  and  the  position  of  the  forearm  is  one 
of  prononneed  abduction.  In  other  words,  the  carrying  angle  is 
greatly  exaggerated. 

A  third  form  of  luxation,  so  rare  as  to  scarcely  deserve  descrip- 
tion, is  one  of  iitward  luxation.  In  this  type  the  upper  end  of 
tlie  ulna  is  displaced  inward  so  that  the  sigmoid  embraces  the  epi- 
trochlea,  while  the  radius  remains  in  contact  with  the  capitellum. 
The  interosseous  membrane,  oblicpie  and  orbicular  ligaments  are 
of  necessity  ruptured  and  the  upper  part  of  the  forearm  is  greatly 
broadened. 

In  all  three  forms  of  luxation  of  the  ulna  the  head  of  tlie  radius 
probably  suffers  a  slight  subluxation,  but  since  it  remains  in  contact 
with  the  capitellum  it  may  for  practical  ])urposes  be  considered 
in  nornud  position. 

Treatment. — In  hacl-icard  luxations  reduction  is  easily  accom- 
plished by  extension  and  counter-extension  in  nuich  the  same  way 
as  has  been  described  in  the  "Treatment"  of  "Dislocations  of  the 
Elbow."  The  adduction,  which  is  due  to  the  radius  remaining  in 
place,  must  be  taken  into  account  and  requires  a  forced  abduction 
of  the  elbow  as  extension  and  counter-extension  are  being  made. 

In  forward  luxations  the  ulna  is  returned  to  its  normal  posi- 
tion by  iuM^ard  rotation  of  the  upper  end  of  the  forearm,  accom- 
panied by  adduction  of  the  forearm  as  the  olecranon  clears  the 
trochlea. 

The  After-Treatment,  Operative  Treatment  and  Prognosis  are 
similar  to  those  already  given  under  "Luxations  of  the  Elbow," 
pages  170,  171  and  174. 


CHAPTER  XII. 

DISLOCATIONS  OF  THE  HEAD  OF  THE  RADIUS. 

Surgical  Anatomy. — The  head  of  the  radius  may  be  likened  to  a 
short  cylinder.  The  upper  end  of  the  cylinder  articulates  with 
the  capitellum  and  is  slightly  concave.  The  sides  of  the  cylinder 
are  in  contact  with  the  orbicular  ligament  and  lesser  sigmoid  cavity 
while  the  lower  end  of  the  cylinder  is  continued  into  the  neck  of 
the  radius.  The  lower  end  is  slightly  less  in  diameter  than  the 
upper  end  of  the  cylinder,  and  the  orbicular  ligament  thus  secures 
a  hold  on  the  upper  extremity  of  the  bone  which  tends  to  prevent 
downward  displacement.  The  interosseous  membrane  and  the  ob- 
lique ligament,  together  with  the  orbicular  ligament,  bind  the 
radius  to  the  ulna  though  they  allow  free  motion  in  pronation  and 
supination.  The  external  lateral  ligament  of  the  elbow  is  not 
attached  to  the  radius  but  divides  and  blends  with  the  orbicular 
ligament,  passes  in  front  of  and  behind  the  radial  head,  and  is  at- 
tached to  the  ulna  anterior  and  posterior  to  the  lesser  sigmoid 
cavity.  The  head  of  the  radius  articulates  with  the  lower  end  of 
the  humerus  and  with  the  ulna  at  the  lesser  sigmoid  cavity. 

The  radial  head  may  be  displaced :  backward,  outward,  forward 
or  downward.  The  exact  mechanism  of  dislocations  of  the  radius 
is  not  clear.  The  matters  of  importance  are  that  the  head  is  dis- 
placed and  requires  reduction.  Fracture  of  the  radial  head  or 
neck  or  of  the  upper  end  of  the  ulna  may  accompany  the  luxa- 
tion. 

Malgaigne's  luxation  (downward  subluxation)  has  also  been  the 
subject  of  much  discussion  and  there  is  little  known  concerning 
the  mechanism  of  the  injury.  The  consensus  of  opinion,  however, 
is  that  there  is  a  slight  downward  luxation  of  the  radial  head,  and 
that  there  may  be  some  infolding  of  the  ligaments  between  the 
articular  surfaces.  This  luxation  is  confined  to  children,  usually 
under  three  or  three  and  a  half  years  of  age,  and  is  due  to  trac- 
tion in  the  axis  of  the  radius. 

There  is  no  hard  and  fast  line  to  be  drawn  between  outward  and 

177 


178  FRACTURES   AND   DISLOCATIONS 

backward  luxations  of  tlio  radial  head,  one  form  merges  into  the 
otlier.  The  relation  ])etween  these  two  types  is  much  the  same 
as  that  already  noted  between  backward  and  outward  luxations 
of  the  elbow.  Any  form  of  isolated  luxation  of  tlio  radial  head 
is  rare  as  compared  with  luxations  of  the  elbow. 

Symptoms. — In  any  type  of  luxation  of  the  head  of  tlie  radius 
there  is  pain  in  the  region  of  the  injury  and  loss  of  function  im- 
mediately following  the  accident.  The  deformity  will  vary  with 
tlie  direction  of  the  displacement. 

hi  ihc  bdrhn-ard  or  oiifirard  types  the  head  is  felt  standing  out 
in  a  position  anywliere  between  posterior  and  external  to  its  normal 
position,  and  may  be  identified  by  the  characteristic  cup-shaped  ex- 
tremity and  by  its  rotation  with  the  sliaft  during  pronation  and 
supination.  The  forearm  is,  as  a  rule,  completely  pronated  and  in 
a  position  just  short  of  complete  extension.  Further  examination 
shows  that  supination  is  cheeked  by  the  altered  mechanism  of  the 
joint,  though  strange  to  say  this  function  seems  to  be  regained  in 
old  unreduced  luxations. 

//(  forward  luxations  the  elbow  is  partially  flexed  and  the  fore- 
arm may  be  either  supinated  or  pronated,  usually  the  latter.  Pro- 
nation is,  as  a  rule,  complete,  and  passive  supination  blocked. 
Flexion  beyond  a  right  angle  is  never  possible  in  recent  cases;  the 
head  of  the  radius  coming  in  contact  with  the  anterior  surface  of 
the  bone  prevents  flexion.  Palpation  of  the  forearm  below  the 
external  condyle  reveals  the  absence  of  the  radial  head  from  its 
normal  position.  The  bend  of  the  elbow  is  usually  swollen  and 
the  displaced  end  of  the  bone  may  be  palpated,  though  it  is  seldom 
as  distinctly  felt  as  is  the  case  in  backward  and  outward  luxations. 
Old  unreduced  cases  may  show  remarkable  restoration  of  function 
as  in  the  backward  and  outward  types. 

Downwurd  luxation  is  productive  of  very  mild  symptoms.  The 
child  flinches  at  the  time  of  the  injury  and  may  cr^'  out.  Dis- 
inclination to  use  the  arm  is  at  once  noted,  the  forearm  being  held 
in  a  position  of  slight  flexion  and  complete  pronation.  The  child 
suffers  little  or  no  pain  as  long  as  the  elbow  is  not  brought  into 
play,  and  accordingly  the  patient  is  very  averse  to  liaving  the  mem- 
ber examined  or  in  any  way  disturbed.  If  it  were  not  for  this 
disinclination  to  use  of  the  member,  the  injuiy  might  frequently 
escape  recognition.  There  is,  as  a  rule,  no  deformity  about  the 
elbow  to  be  appreciated  by  either  inspection  or  palpation.     In  some 


DISLOCATIONS    OF    HEAD    OF'^    RADIUS 


179 


Fig.  249. — Forward  luxation  of  tlie  liead  of  radius.  Prominence  indicated  by  arrow 
is  caused  by  tiie  displaced  radial  head.  Note  the  exaggerated  carrying  angle  which  re- 
sults from  the  head  of  the  radius  not  bearing  on  the  capitellum  of  the  humerus.  Flexion 
limited  by  the  displaced  radial  head. 


Fig.   250.  Fig.    2.51. 

Figs.   250  and  251. — X-rays  of  same  case  showing  luxated  radial  head. 


180  FRACTURES   AND    DTRI.OCATIONS 

instances  there  iii;iy  lie  a  sli^lit  separation  l)etween  tlie  head  of 
the  radius  and  capitt'lluin  bnt  this  is  usually  so  trivial  as  to  be 
scarcely  perceptible.  Loss  of  function  may  persist  for  a  long  time 
if  proper  treatment  is  not  instituted,  though  ultimate  disability 
of  the  nicniber  seldom  occurs. 

Diagnosis. — The  diagnosis  of  luxations  of  the  radial  licad  depends 
on  the  restriction  of  motion,  the  characteristic  attitude  and  pal- 
pation of  the  head  of  the  bone  in  its  displaced  position  while  the 
upper  end  of  the  ulna  remains  normally  placed.  The  diagnosis 
of  IMalgaigne's  luxation  is  based  largely  on  the  history  of  the  case 
and  the  disinclination  on  the  part  of  the  child  to  use  the  member. 
The  history  is  typical.  The  condition  is  the  result  of  the  per- 
nicious habit  of  lifting  a  child  by  the  hand ;  mothers  are  prone  to 
do  this  in  helping  children  on  and  off  of  street  cars,  and  in  hurry- 
ing them  along  the  street.  Following  injury  to  the  arm  in  this 
way  the  child  fails  to  use  the  member  and  objects  to  having  it 
disturbed. 

The  X-ray  is  of  value  chiefly  in  determining  associated  lesions, 
such  as  fracture  of  the  radial  head  or  neck  or  of  the  external  con- 
dyle of  the  humerus,  or  a  break  in  the  ulna. 

Treatment. — Reduction  in  the  backward  and  outward,  types  is 
usually  easy,  though  the  head  may  tend  to  slip  out  again  as  soon 
as  the  arm  is  released.  Retentive  dressings  should  be  in  readiness 
before  returning  the  head  to  its  normal  position.  Extension  and 
counterextension,  accompanied  by  direct  pressure  on  the  head  in 
the  direction  of  the  capitellum,  will,  as  a  rule,  effect  reduction. 
The  degree  of  flexion  in  which  there  is  least  tendency  for  the  head 
to  slip  out  of  position  should  be  determined  in  each  case  and  the 
joint  immobilized  in  this  position.  A  pad  maintained  in  place 
by  straps  of  adhesive  and  exerting  direct  pressure  on  the  upper 
end  of  the  bone  may  be  of  service  in  preventing  recurrence  of  de- 
formity. The  head  of  the  bone  may  be  fractured  against  the 
capitellum  as  it  is  driven  out  of  place,  and  when  this  complication 
exists  it  may  increase  the  tendency  to  reluxation. 

In  forward  luxations  similar  principles  are  employed.  Reduc- 
tion is  accomplished  by  extension,  counterextension  and  direct 
backward  pressure  on  the  displaced  head.  "When  the  head  of  the 
radius  is  felt  to  move  backward  the  elbow  is  flexed  and  the  ma- 
nipulation is  complete.  To  prevent  recurrence  of  deformity  the 
elbow  should  be  immobilized  in  a  position  just  short  of  acute  flexion 


DISLOCATIONS   OF    HEAD   OF   RADIUS  181 

(see  Fig.  210).  When  luxation  of  the  radial  head  is  complicated 
by  fracture  of  the  ulna,  increased  difficulty  may  be  experienced 
in  preventing-  reluxation.  In  addition  to  treating  the  dislocation 
we  have  the  fragments  of  the  ulna  to  maintain  in  apposition. 
Under  these  circumstances  internal  and  external  angular  splints 
will  be  found  more  efficient  than  the  position  of  acute  flexion  ad- 
vised in  the  uncomplicated  anterior  dislocation.  If  the  elbow  is 
to  be  immobilized  at  a  right  angle  the  ordinary  internal  and  ex- 
ternal angular  splints  will  be  satisfactory.  If,  however,  some  other 
degree  of  flexion  is  desired  plaster  splints  may  be  needed.  If 
ordinary  means  are  not  efficient  in  preventing  deformity  in  either 
the  fracture  or  the  luxation  operation  should  be  resorted  to. 

The  reduction  of  Malgaigne's  luxation  is  usually  accomplished 
without  difficulty.  It  consists  in  forcing  the  head  of  the  radius 
upward  against  the  capitellum,  and  is  accomplished  in  the  fol- 
lowing manner.  The  surgeon  grasps  the  lower  part  of  the  arm  to  fix 
the  humerus  while  the  opposite  hand  secures  the  forearm  at  about 
its  middle;  the  forearm  is  then  rotated  (supinated  and  pronated) 
while  upward  pressure  in  the  axis  of  the  radius  forces  the  head  of 
the  bone  up  against  the  capitellum.  Keduction  is  usually  accom- 
panied by  a  soft  click,  after  which  all  the  functions  of  the  joint 
are  found  to  be  normal  and  painless.  Aften  this  maneuver  is 
complete  the  elbow  is  tested  by  carrying  the  forearm  through 
flexion,  extension,  supination  and  pronation.  If  the  function  is 
not  completely  restored  and  painless  the  manipulation  should  be 
repeated.  It  may  be  necessary  to  alternate  extension  with  upward 
pressure.  It  will  only  be  a  few  hours  following  reduction  until 
the  child  is  using  the  arm  freely  and  without  discomfort.  The 
condition  is  not  a  serious  one  even  if  allowed  to  go  unreduced, 
but  proper  treatment  will  relieve  the  child  and  obviate  much 
anxiety.  The  displacement  will  not  return  unless  the  same  forces 
which  first  produced  the  subluxation  are  again  inflicted  on  the  parts, 
and  accordingly  all  that  is  necessary  to  prevent  recurrence  is  to 
see  that  those  having  to  do  with  the  child  are  thoroughly  informed 
and  cautioned  concerning  the  manner  in  which  the  injury  was  pro- 
duced. 

Operative  Treatment. — The  open  method  is  indicated  when  other 
means  fail  to  accomplish  and  maintain  reduction  for  the  correction 
of  ancient  luxations  and  occasionally  in  the  treatment  of  compli- 
cations.    A   longitudinal   incision   is   made   over  the  head   of  the 


182  fracti;res  and  dislocations 

radius,  tlie  bone  exposed  and  rednetion  effeeted  by  direct  nianipii- 
latioii.  It  may  be  possible  to  suture  tlie  torn  orbieular  ligament 
after  the  head  has  been  replaced,  lliouiili  in  some  eases  it  may  be 
dififienlt  to  recognize  this  structure.  In  any  case  it  is  proper  to 
suture  the  structures  surrounding  the  upper  end  of  the  bone  in 
such  a  manner  as  to  prevent  redisplacement.  When  the  radial 
head  is  much  connninuted  it  is  often  better  to  remove  the  frag- 
ments, round  up  the  end  of  the  bone  and  suture  the  tissues  about 
it.  Rotation  of  the  upper  end  of  the  bone,  as  evidenced  by  supina- 
tion and  pronation,  is  seldom  lost  following  these  operations  if  the 
axis  of  the  radial  shaft  remains  unchanged.  INIoreover  these  cases 
usually  show  a  surprising  stability  of  the  joint  when  recovery  is 
complete. 

Complicating  fracture  of  the  upper  end  of  the  ulnar  shaft  is 
not  an  uncommon  condition  accompanying  anterior  luxation  and 
may  demand  operation  to  maintain  reduction  in  both  fracture 
and  dislocation.  The  dislocation  is  not  particularly  prone  to  recur 
but  the  fracture  is  sometimes  difficult  to  hold  in  reduction  because 
of  the  instability  of  the  radio-humeral  articulation.  It  is  more 
often  necessary  to  wire  the  fracture  in  the  ulna  than  it  is  to  operate 
on  the  luxation.  If  the  ulna  is  approached  through  a  posterior 
incision  and  the  fragments  secured  by  internal  fixation  it  will  often 
be  possible  to  treat  the  luxation  in  the  flexed  position,  and  thus 
prevent  displacement  of  the  radial  head. 

If  the  upper  end  of  the  bone  has  been  allowed  to  remain  dis- 
placed the  removal  of  longitudinal  pressure  commonly  results  in 
an  over-growth  of  the  bone  with  a  corresponding  increase  in 
length.  In  operating  on  ancient  luxations,  therefore,  it  may  be 
necessary  to  resect  the  head  of  the  bone  before  the  shaft  can  be 
brought  back  into  alignment.  Old  anterior  luxations  come  to 
operation  more  frequently  than  either  the  outward  or  posterior 
types  because  of  the  loss  of  acute  flexion  in  forward  dislocations. 
The  excellent  functional  results  following  operation  on  old  cases, 
even  when  the  head  is  resected,  are  often  surprising. 

]\Ialgaigne 's  subluxation  never  requires  operation. 

After-Treatment, — The  elbow  should  be  fixed  in  the  position 
hast  favorable  to  recurrence  for  a  period  of  at  least  twenty-five  to 
thirty  days.  In  anterior  luxations  there  is  usually  less  tendency 
to  recurrence  and  accordingly  the  period  of  fixation  need  not  be 
so  long.     Three  to  four  weeks  will,  as  a  rule,  be  ample.     When  frac- 


DISLOCATIONS    OF    HEAD   OP    RADIUS  183 

ture  complicates  luxation  union  of  the  fragments  is  the  chief  con- 
sideration in  the  after-treatment  and  the  retentive  dressings  should 
be  removed  only  after  one  is  satisfied  that  union  is  firm  (usually 
four  or  five  weeks) .  When  fracture  is  present  the  case  will  require 
more  careful  supervision.  The  traumatic  reaction  is  greater  and 
the  same  precautions  are  to  be  observed  as  cited  under  fractures 
of  the  bones  of  the  forearm.  Malgaigne's  luxation  requires  no 
after-treatment. 

Prognosis. — In  the  uncomplicated  luxation  of  the  head  of  the 
radius,  where  reduction  has  been  effected,  restoration  of  function 
should  he  complete.  If  complications  exist  the  prognosis  varies 
with  the  nature  of  the  associated  injury. 


CHAPTEK  Xlll. 
FRACTURES  OF  THE  l^OXKS  OF  THE  FOREARM. 

In  considering  t'ractiu'es  of  the  i-adiiis  and  ulna  it  will  be  found 
more  satisfactory  to  describe  them  accortling  to  tlie  level  of  the 
break  ratlier  than  to  take  up  eacli  bone  separately  from  end  to 
end.  It  is  well  appreciati'd  that  various  coiubiiiatious  of  fractures 
may  exist  in  the  forearm  regardless  of  the  level;  thus  the  lower 
end  of  the  radius  and  the  upper  end  of  the  ulna  may  be  broken  at 
the  same  time,  or  a  fracture  of  the  neck  of  the  radius  may  be  ac- 
companied by  a  break  in  the  lower  end  of  either  bone.  It  is  mani- 
festly impracticable  to  enter  into  the  details  of  these  various  pos- 
sible cond)inations  of  fracture,  but  if  tlie  student  appreciates  the 
nature  of  the  breaks  as  described  in  the  following  pages  he  wdll 
be  able  to  modify  the  treatment  to  meet  the  requirements  of  un- 
usual combinations  of  fracture  as  they  occur. 

The  order  in  which  fractures  of  the  bones  of  the  forearm  will  be 
considered  is  as  follows : 

Fractures  of  the   upper  end  of  the  ulna. 
Fractures  of  the  ujjper  end  of  the  radius. 
Fractures  of  the  shafts  of  the  radius  and  ulna. 
Fractures  of  the  lower  end  of  the  ulna. 
Fractures  of  the  lower  end  of  the  radius. 


184 


CHAPTER  XIV. 

FRACTURES  OF  THE  UPPER  END  OP  THE  ULNA. 

Surgical  Anatomy. — Much  that  has  already  been  said  concerning 
the  anatomy  of  "Fractures  of  the  Lower  End  of  the  Humerus" 
(page  120)  and  "Dislocations  of  the  Elbow"  (page  154)  is  equally 
important  in  fractures  of  the  upper  end  of  the  ulna  since  the  re- 
gion is  the  same.  Fractures  of  the  upper  extremity  of  this  bone 
may  be  of  the  olecranon,  the  coronoid  or  just  below  the  latter 
process  in  the  upper  thickened  portion  of  the  shaft.  Occasionally 
the  nature  of  the  break  or  its  position  is  atypical.  The  most  im- 
portant and  at  the  same  time  the  most  common  fracture  occurring 
in  the  upper  end  of  the  ulna  is  of  the  olecranon  process.  This 
process  is  large,  thick  and  curved,  and  projects  upward  behind 
the  lower  end  of  the  humerus  when  the  elbow  is  extended.  Its 
upper  surface  is  roughly  quadrilateral  and  affords  attachment  to 
the  tendon  of  the  triceps.  A  portion  of  this  tendon  is  continued 
through  a  heavy  aponeurosis  onto  the  posterior  surface  of  the 
process,  and  thus  the  pull  of  the  triceps  may  be  exerted  on  the 
lower  fragment  in  fractures  of  the  olecranon,  when  the  aponeu- 
rosis is  not  torn.  The  upper  margin  of  the  olecranon,  anterior  to 
the  insertion  of  the  triceps,  affords  attachment  to  the  posterior 
bands  of  the  lateral  ligaments.  These  ligaments  serve  to  keep 
the  anterior  surface  of  the  process  in  contact  with  the  trochlea 
when  broken  off  from  the  remainder  of  the  bone.  The  posterior 
surface  of  the  olecranon  is  covered  by  a  bursa  and  when  this 
bursa  is  inflamed  or  enlarged  as  in  "  miner 's  elbow ' '  the  deformity 
may  be  marked.  It  does  not  resemble  fracture  but  has  been  mis- 
taken for  it. 

The  interior  of  the  olecranon  is  composed  of  a  fine  ineshed  can- 
cellous tissue,  while  the  surface  consists  of  compact  tissue,  varying 
in  thickness  in  different  regions  of  the  process.  The  compact  bone 
is  thickest  in  the  region  corresponding  to  the  sigmoid  cavity.  That 
covering  the  posterior  surface  of  the  process  is  a  little  heavier 
than  occurs  in  the  adjoining  regions.     The  cancellous  tissue  below 

185 


186  FRACTURES   AND    DISI.OCATIONS 

tlie  coronoid  process  is  quite  wide  meshed  and  not  as  strong  as 
that  found  in  the  olecranon.  About  lialf  an  inch  below  the  coro- 
noid the  compact  bone  begins  to  grow  thicker  and  rapidly  in- 
creases in  weight  as  the  middle  of  the  shaft  is  approached.  The 
structure  of  the  bone  in  the  olecranon  explains  the  inadvisability 
of  using  nails  or  screws  when  securing  the  fragments  by  internal 
fixation.     (See  Fig.  269,  page  204.) 

The  upper  epiphysis  of  the  ulna  consists  of  a  thin  layer  or  scale 
of  bone  at  the  top  of  the  olecranon  which  first  shows  ossification 
ill  tlu-  tenth  year,  and  joins  the  shaft  during  the  sixteenth  or 
^;evenleenth  year.  The  fact  that  the  tricejis  is  attached  not  only 
to  the  uppei-  end  of  the  olecranon  but  to  the  posterior  surface, 


Fig.   252. — Avulsion   of   corlicul  layer   of   fompact   tissiiu   in   wliirh   triceps   finds   inser- 
tion. 

accounts  for  the  comparative  rarity  of  avulsion  and  separation  of 
this  epiphysis.  The  line  of  the  epiphyseal  cartilage  has  been 
mistaken  for  fracture. 

As  previously  stated  the  powerful  triceps  is  inserted  into  the 
olecranon  process  of  the  ulna,  but  its  antagonist  the  biceps  is  at- 
tached to  the  bicipital  tuberosity  of  the  radius.  Thus  it  will  be 
noted  that  the  heavy  extensor  and  flexor  muscles  of  the  forearm 
are  able  to  balance  each  other  only  because  the  two  bones  of  the 
forearm  are  firmly  bound  together.  Fracture  of  the  olecranon, 
or  fracture  below  the  level  of  the  sigmoid  cavity  with  separation 
of  the  fragments,  destroys  the  balance  between  the  biceps  and 
triceps.  The  brachialis  anticus  attached  to  the  coronoid  process 
is  a  flexor,  and  in  fractures  below  the  process  this  muscle  tends  to 


FRACTURES  OP  UPPER  END  OP  ULNA  187 

counteract  the  pull  of  the  triceps,  but  its  relative  weakness  results 
in  the  upper  fragment  being  carried  into  extension  if  the  aponeu- 
roses have  been  torn  sufficiently  to  allow  deformity. 

The  mechanism  of  fracture  of  the  olecranon  has  been  the  subject 
of  considerable  discussion ;  suffice  it  to  say  that  most  fractures  of 
the  olecranon  are  probably  the  result  of  a  combination  of  direct 
violence  and  muscular  action.     Thus  when  a  person  falls  heavily 


Fig.    253. — Practuve   of   olecranon.      Elbow    extended. 


Fig.   254. — Same    case.      Elbow    slightly    flexed,     showing    increase    of    distance    be- 
tween fragments. 

on  the  outstretched  hand  the  triceps  is  firmly  fixed  in  anticipation 
of  the  blow.  If  the  force  is  great  the  hand  is  forced  toward  the 
body  and  a  heavy  strain  is  sustained  by  the  process.  Under 
these  circumstances  the  elbow  usually  strikes  the  ground  as  flexion 
increases.  Thus  there  is  a  combination  of  direct  and  indirect 
violence,  and  it  is  difficult  to  distinguish  which  of  the  two  is  the 
more  important  etiologic  element.     Cases  are  known  in  which  the 


188  FRACTURES   AND   DISLOCATIONS 

injury  seems  to  have  l)i'eii  jirodneed  entirely  by  muscular  action, 
while  in  other  instances  direct  violence  alone  has  undoubtedly 
been  responsible  for  the  fracture.  Fracture  of  the  olecranon 
produced  experimenlally  by  dirt^ct  violence  has  been  of  a  different 
type  than  that  commoidy  seen  clinically.  The  amount  of  displace- 
ment of  the  upper  fragment  is  usually  greatest  in  cases  resulting 
from  nuiscular  aetioii  though  great  separation  is  sometimes  seen 
where  the  injui-y  has  been  caused  by  a  blow  on  the  elbow.  The 
displacenuMit  depends,  to  a  great  extent,  on  the  tearing  of  the 
aponeurosis  on  tlie  posterior  surface  of  the  ]>r()eess.  The  line  of 
fiaelure  is  usually  transverse  and  most  often  oeeui's  at  the  l)ottom 
of  the  sigmoid  fossa  where  the  process  is  thinnest.  The  break 
usually  enters  the  joint  ap.d  when  compound  the  elbow  is  exposed 
to  infection.  The  deformity  is  usually  characteristic ;  the  upper 
fragment  follows  the  curved  surface  of  the  trochlea  so  that  the 
space  left  between  the  broken  surfaces  is  the  shape  of  a  truncated 
wedge,  with  the  narrow  end  of  the  wedge  transversely  situated 
against  the  trochlea  while  the  base  stands  backward  and  down- 
ward. 

Fracture  of  the  coronoid  is  an  extremely  rare  condition  except 
as  a  complication  of  backward  dislocation  of  the  elbow  (q.  v.). 

In  fractures  below  the  coronoid  it  is  not  uncommon  to  find  the 
head  of  the  radius  luxated  forward,  which  condition  has  been 
described  under  "Dislocations  of  the  Head  of  the  Radius." 

Symptoms.— Immediately  following  the  injury  the  patient  finds 
that  he  is  unable  to  actively  extend  the  forearm,  though  motion 
may  be  accomplished  passively  or  by  the  action  of  gravity.  ^lotion 
is  painful  and  the  patient  usually  supports  the  forearm  in  a  semi- 
flexed position  with  the  uninjured  member.  When  separation  is 
present  the  deformity  is  characteristic  if  seen  early  before  the 
elbow  is  much  swollen.  The  point  of  the  elbow  is  gone ;  the  pos- 
terior aspect  of  the  joint  has  a  rounded  effect  instead  of  its  normal 
angularity,  and  in  some  cases  the  position  of  the  displaced  frag- 
ment may  be  determined  by  inspection  alone.  Swelling  of  the 
parts  comes  on  rapidly  in  most  cases,  and  after  it  is  well  established 
there  is  nothing  characteristic  in  the  outline  to  differentiate  the 
condition  from  the  swollen  states  seen  following  other  injuries 
about  the  elbow.  Palpation,  however,  readily  clears  up  the  diag- 
nosis as  sho\\Ti  in  Fig.  256.  In  many  cases  there  is  separation  of 
the  fragments  when  the  forearm  is  flexed  but  none  with  the  elbow 


FRACTURES   OP    UPPER   END   OP    TJLNA 


189 


in  extension,  and  accordingly  the  evidences  of  separation  will  vary 
with  the  degree  of  flexion  at  the  elbow.  Lateral  mobility  may  be 
noted,   especially   abnormal   abduction   of   the   forearm.     The   dis- 


Fig'.  255. — Fracture  of  the  olecranon  about  one  week  following  the  accident.  The 
characteristic  deformity  seen  in  recent  cases  is  here  obscured  by  the  intense  swelling. 
Note   ecchymosis.      Diagnosis   cannot  be   made  by   inspection    alone. 


Fig.  256. — Same  case.  Diagnosis  e.'^tablished  by  palpation.  Thumb  rests  on  top 
of  olecranon.  The  index  finger  occupies  the  depression  between  the  fragments.  The 
middle  finger  rests  on  the  upper  end  of  the  lower  fragment.  Note  how  the  index  finger 
sinks  in  between  the  fragments. 


tance  between  the  fragments  is  variable,  the  greatest  separation 
being  seen  in  old  cases  with  fibrous  union,  in  which  the  bond  has 
stretched  with  use. 


190  FRACTURES   AND   DISLOCATIONS 

It  is  not  uiieoniinon  to  see  fracture  of  the  oleoranon  with  little 
or  no  separation  of  the  fragments,  and  nnder  these  cirennistanees 
some  of  the  cJiaracteristic  symptoms  will  he  wanting.  The  power 
of  active  extension  will  be  slightly  if  at  all  disturbed  though  the 
action  will  be  painful.  Lateral  mobility  of  the  process  and  crepitus 
are  usually  present  though  they  are  often  not  well  marked  when 
the  fracture  has  been  accompanied  by  only  slight  tearing  of  the 
aponeurosis.  With  separation  of  the  fragments  crepitus  can  only 
be  elicited  when  the  fragments  are  approximated  and  the  broken 
surfaces  rubbed  together.  Ecchymosis  is  almost  invariably  seen 
within  twenty-four  hours  of  the  accident. 

In  compound  cases  the  wound  is  usually  situated  on  the  pos- 
terior aspect  of  the  elbow  and  it  may  be  possible  to  see  the  line 
of  fracture  and  the  displaced  fragment. 

Fractures  of  the  coronoid  and  fractures  of  the  ulna  just  below 
this  process  have  been  considered  under  ''Dislocations  of  the 
Elbow."  Isolated  fracture  of  the  ulna  just  below  the  coronoid  is 
an  extremely  rare  accident  and  is  usually  the  result  of  direct 
violence.  It  will  be  accompanied  by  abnormal  mobility,  crepitus, 
loss  of  function,  etc. 

Diagnosis. — If  the  case  is  seen  early  there  will  usually  be  little 
difficulty  in  recognizing  fracture  of  the  olecranon  if  the  sjnnptoms 
just  described  are  sought.  Fracture  without  displacement  may 
escape  recognition  if  the  parts  are  not  thoroughly  and  carefully 
examined.  The  posterior  border  of  the  ulna  is  subcutaneous 
throughout  and  by  tracing  it  upward  from  below  the  position  of 
the  fracture  and  the  displaced  fragment  can  as  a  rule  be  felt. 
Even  where  there  is  no  displacement  it  is  often  possible  to  detect 
some  loss  of  alignment  on  the  posterior  border  of  the  olecranon 
and  by  grasping  the  process  laterally,  motion  and  crepitus  may  be 
elicited.  In  establishing  a  diagnosis  of  fracture  of  the  olecranon 
the  elbow  should  be  examined  systematically  as  already  described 
under  "Fractures  of  the  Lower  End  of  the  Humerus"  (page  137) 
and  in  "Dislocations  of  the  Elbow"  (page  163). 

The  condition  must  be  differentiated  especially  from  fractures 
of  the  lower  end  of  the  humerus  and  backward  luxation  of  the 
elbow. 

Treatment. — The  methods  of  treatment  employed  will  depend 
entirely  on  the  conditions  present.  Where  there  is  no  separation 
the  right  angle  splint  will  meet  the  requirements  of  the  case,  in 


FRACTURES  OP  UPPER  END  OF  ULNA 


191 


V 


V; 


addition  diagonal  strips  of  zinc  oxide  adhesive  should  be  so  placed 
as  to  bind  down  the  olecranon  and  relieve  the  upper  fragment 
of  the  displacing  action  of  the  triceps.  When  displacement  exists 
the  time-honored  straight  splint  is  indicated.  The  elbow  slioiiUI 
not  be  treated  in  extreme  extension  because  in  the 
first  place,  the  position  becomes  intolerable  to  the 
patient  in  a  short  time  and  secondly,  the  tip  of  the 
olecranon  in  this  attitude  is  not  sufficiently  promi- 
nent to  afford  the  proper  purchase  for  the  straps 
of  adhesive  used  in  binding  the  fragment  in  a  po- 
sition of  reduction.  A  straight  board  may  be  used 
a  little  broader  than  the  arm,  and  with  sufficient 
padding  at  the  elbow  to  allow  a  few  degrees  of 
flexion.  The  splint  should  be  secured  by  three 
strips  of  adhesive  plaster  encircling  the  member; 
one  at  either  extremity  of  the  splint  and  the  third 
just  above  the  elbow.  It  should  extend  from  a  point 
just  below  the  axillary  fold  to  the  wrist;  there  is 
little  to  be  gained  by  extending  the  splint  downward 
to  include  the  hand,  the  patient  being  much  more 
comfortable  when  some  action  at  the  wrist  and 
fingers  is  allowed.  The  straight  splint  is  very  cum- 
bersome at  best  and  is  not  a  desirable  method  of 
fixation  when  other  means  can  be  made  to  ac- 
complish the  purpose-  A  neat  and  satisfactory 
method  of  making  a  straight  splint  is  to  use  quarter- 
inch  iron  wire ;  this  is  bent  to  fit  the  arm  in  a  posi- 
tion short  of  complete  extension  and  bandaged  the 
same  as  the  Cabot  posterior  wire  splint  employed 
in  the  treatment  of  fractures  of  the  leg.  A  slight 
bend  is  made  at  the  elbow  to  allow  a  little  flexion 
of  the  forearm.  When  the  fracture  is  compound 
it  should  be  treated  according  to  the  principles  laid 
down  under  ''The  Treatment  of  Compound  Frac- 
tures and  Luxations,"  on  page  789. 

Operative  Treatment. — Of  late  years  operation  has,  to  a  great 
extent,  supplanted  the  ordinary  methods,  and  there  has  been  a 
great  deal  of  discussion  on  the  subject,  pro  and  con.  There  is 
a  large  proportion  of  cases  which  make  excellent  functional  re- 
coveries without  operation,  and  it  is  unwise  to  resort  to  the  open 


Fig.  257. — Illus- 
trates the  use  of  the 
straight  splint  in  the 
non-operative  treat- 
ment of  fracture 
of  the  olecranon. 
Note  the  diagonal 
strap  of  adhesive 
which  binds  the  up- 
per fragment  in  po- 
sition. Slight  flex- 
ion of  the  elbow 
affords  a  better  hold 
for  this  strip  of  ad- 
hesive. 


192  FRACTURES   AND    DISLOCATIONS 

method  in  all  cases.  When  the  fracture  is  not  conipouncl  and  there 
is  no  displacement  of  the  fragments  operative  intervention  can  ac- 
complish nothing,  hut  on  the  other  hand  when  there  is  displacement 
which  cannot  be  perfectly  corrected  or  when  the  fracture  is  com- 
pound there  is  no  method  that  will  be  as  successful  as  operation. 
Between  these  two  types  is  a  third  class  in  which  the  best  mode  of 
procedure  is  not  so  evident.  When  the  condition  is  not  compound 
and  there  is  only  moderate  separation,  wliich  can  be  faii-ly  well 
corrected  by  other  means,  the  question  tlicn  arises:  dors  the  ])atient 
prefer  to  submit  to  an  operation  for  the  sake  of  a  more  rapid 
and  perfect  result,  or  would  he  rather  endure  a  more  protracted 
convalescence  and  assume  the  responsibility  of  an  imperfect  func- 
tional result  whicli  may  go  with  fibrous  union  .'  In  llicsc  l)order- 
land  cases  the  situation  should  be  laid  before  the  patient  and  he 
should  be  the  one  to  assume  the  responsibility  if  operation  is 
rejected.  Fibrous  union,  when  the  fragments  are  close  and  the 
mass  of  fibrous  tissue  heavy,  is  usually  accompanied  by  excellent 
results,  and  cases  in  which  these  conditions  obtain  are  a  strong 
argnment  against  operation.  It  should  be  remembered,  however, 
that  it  is  impossible  to  foretell  just  how  strong  fibrous  union 
will  be  in  a  given  case.  The  age,  condition  and  occupation  of 
the  patient  are  factors  which  must  be  taken  into  consideration 
in  advising  the  proper  method  of  procedure.  Limitation  of  full 
extension  is  directly  proportionate  to  the  separation  of  the  frag- 
ments. If  the  broken  olecranon  is  displaced  upward  it  becomes 
seated  in  tlie  olecranon  fossa  before  the  elbow  is  fully  extended, 
and  thus  motion  is  limited.  Full  extension,  therefore,  cannot  be 
expected  unless  the  fragments  are  in  accurate  apposition.  It  might 
be  stated  as  a  rule  that  young  or  middle  aged  persons,  especially 
of  the  working  class,  should  be  operated  when  the  fragments  can- 
not be  approximated  l)y  ordinary  methods.  By  the  open  method 
convalescence  is  shortened  and  the  function  of  the  joint  is  more 
completely  restored. 

The  process  is  exposed  through  a  longitudinal  incision  external 
to  the  posterior  surface  of  the  olecranon.  The  scar  in  this  position 
is  not  exposed  to  pressure  when  the  patient  rests  the  elbow  on  a 
table  or  other  convenient  object.  After  the  fragments  are  ex- 
posed two  transvei'se  holes  are  drilled  one  above  and  the  other 
below  the  plane  of  the  fracture.  All  loose  tissues  are  then  cleared 
away  between  the  two  fractured  surfaces  and  the  upper  fragment 


FRACTURES  OF  UPPER  END  OF  ULNA 


]93 


brought  down  and  accurately  fitted  into  the  serrations  of  the 
lower  one.  Suture  material  is  then  passed  through  the  holes  and 
the  fragments  solidlv  secured  in  position  Instead  of  this  method 
a  heavy  mattress  suture  may   be   placed,   as  shown   in    Fig.   259. 


Fig.   258. — Fracture     of     olecranon     showing     separation     of    fragments     in     spite     of 
dressings  tending  to  correct  the  deformity. 


Fig.   259. — Same  case  sliowing  accurate  reduction   following  operation  in  which  mat- 
tress suture  of  silver  wire  was  used  to  maintain  reduction. 


There  has  been  considerable  discussion  concerning  the  best  type 
of  suture,  and  of  late  absorbable  materials  such  as  chromic  catgvit 
and  kangaroo  tendon  have  been  frequently  employed.  The  author 
much  prefers  wire  to  absorbable  material,  since  the  latter  is  more  or 
less  likely  to  soften  and  stretch  before  the  callus  is  firm  enough  to 


194  FRACTURES   AND    DISLOCATIONS 

withstand  llic  unavoidable  tension  of  the  triceps,  .and  when  it 
does  there  will  bo  at  least  some  slight  separation  of  the  fragments. 
Silver  wire  h,as  no  streteh  in  it  and  will  hold  the  fragments  in 
position  as  long  as  may  be  necessary,  and  in  addition  will  permit 
of  early  and  repeated  passive  motion  with  greater  safety.  (See 
"Operative  Treatment  of  Fraetnres,"  page  758.)  In  compound 
cases  the  wound  sliould  be  irrigated  with  a  few  gallons  of  physi- 
ologic sterile  s<ilt  solution,  and  the  edges  of  the  wound  trimmed 
of  devitalized  tissue  as  described  in  "The  Treatment  of  Compound 
Fractures  and  Luxations,"  on  page  789.  Internal  fixation  of  the 
fragments  should  not  be  performed  at  the  initial  operation  in  com- 
pound eases  though  it  may  be  possible  to  retain  the  fragments  in 
position  by  suturing  the  fascia  covering  the  posterior  surface  of  the 
process,  in  closing  the  wound.  A  secondary  operation  may  be  done 
after  the  Avound  (rendering  the  condition  compound),  has  healed 
and  the  danger  of  infection  has  passed. 

Pillowing  a  firm  internal  fixation  of  the  frag-ments  the  upper 
extremitj^  may  be  immobilized  with  an  internal  right  angle 
splint. 

Old  cases  of  fracture  of  the  olecranon  sometimes  require  opera- 
tion because  of  separation  of  the  fragments  and  loss  of  function. 
The  difficulty  is  purely  mechanical  and  calls  for  mechanical  cor- 
rection. The  joint  is  approached  through  a  longitudinal  incision 
as  just  described;  the  fibrous  tissue  is  excised  and  the  upper  frag- 
ment brought  down  into  apposition  with  the  lower.  The  ends  of 
the  fragments  must  be  freshened  before  being  sutured  together, 
but  as  little  bony  tissue  should  be  removed  as  possible.  In  cases 
of  long  standing  it  may  be  necessary  to  lengthen  the  tendon  of  the 
triceps  so  that  the  elbow  may  be  fully  flexed  after  the  fragments 
have  been  sutured  together. 

In  rare  instances  fracture  of  the  coronoid  may  require  operation 
if  the  fragment  is  large  and  much  displaced,  and  if  immobilization 
of  the  elbow  in  the  flexed  position  does  not  effect  reduction.  It 
will  usually  be  possible  to  retain  the  fragment  by  suture  of  the  soft 
parts  since  there  is  little  displacing  action  if  the  elbow  is  subse- 
quently fixed  and  treated  in  the  flexed  position.  In  making  the 
incision  to  expose  this  process  the  greatest  care  should  be  exercised 
to  avoid  injury  to  the  brachial  artery  and  median  nerve  as  they 
pass  across  the  bend  of  the  elbow. 

Fracture  of  the  upper  end  of  the  ulna  below  the  coronoid  is 


FRACTURES    (JF    IJPPFJR    ENU    OF    ULNA  195 

especially  rare  and  seldom  requires  operation  except  when  accom- 
panied by  anterior  dislocation  of  the  elbow.  The  treatment  of  this 
condition  has  been  considered  under  "Dislocations  of  the  Elbow," 
page  170. 

After-Treatment. — If  non-operative  methods  have  been  followed 
and  the  straight  splint  used  the  arm  should  be  inspected  daily  for 
the  first  two  weeks  to  see  that  there  is  no  undue  constriction  of  the 
parts  and  that  the  straps  binding  the  olecranon  down  are  accom- 
plishing the  purpose.  The  same  precautions  are  to  be  observed  if 
the  right  angle  splint  is  employed.  If  the  soft  tissues  have  suffered 
much  injury  it  is  usually  advisable  to  delay  reduction  of  the  frac- 
ture until  the  traumatic  reaction  has  subsided.     During  this  time 


Fig.  260. — Illustrates  method  of  employing  passive  motion  in  the  after-treatment  of 
fractures  of  the  olecranon.  The  thumb  forces  the  olecranon  to  follow  the  shaft  of  the 
ulna  as  the  elbow  is  being  flexed. 

it  is  best  to  treat  the  patient  in  bed  with  the  arm  immobilized  on  an 
internal  right  angle  splint.  The  intermittent  use  of  the  ice  cap 
will  aid  materially  in  controlling  the  reaction.  The  SAvelling  will,  as 
a  rule,  have  subsided  sufficiently  at  the  end  of  a  week  or  ten  days 
to  permit  of  reduction  and  immobilization,  or  operation  if  thought 
best.  Massage  is  of  great  service  after  the  swelling  has  passed  off 
but  is  capable  of  doing  harm  during  the  active  inflammatory  reac- 
tion. Passive  motion  should  be  instituted  at  the  end  of  two  weeks 
but  should  be  guarded,  gentle  and  painless  at  first,  and  the  arm 
should  be  carried  through  only  a  few  degrees  of  flexion.  At  the 
end  of  three  weeks  much  freer  motion  is  permissible  in  manipu- 
lating the  elbow.     The  greatest  care,  however,  should  be  exercised 


196  FRACTURES   AND   DISLOCATIONS 

at  all  times  not  to  cause  separation  of  the  fragments  during  passive 
motion,  especially  if  they  have  not  been  wired.  In  moving  the 
joint  tile  thumb  should  l)e  ])laced  above  the  ])rocess  as  shown  in 
Fig.  260  and  downward  pressure  exerted  on  the  end  of  the  process 
to  force  the  fragment  to  follow  the  movements  of  the  shaft  during 
flexion  of  the  elbow.  Early  passive  motion  is  essential  to  the  pre- 
vention of  adhesions  within  the  joint,  yet  if  not  properly  guarded 
it  may  do  more  harm  than  good.  Union  of  the  fragments  usually 
takes  place  at  the  end  of  three  or  four  weeks,  l)ut  the  callus  is  not 
strong  enough  to  withstand  much  strain  at  this  time.  At  the  end 
of  four  or  five  weeks  immobilization  may  be  discontinued.  At  the 
end  of  two  and  a  half  to  three  months  recovery  is  complete  though 
the  patient  should  be  cautioned  not  to  use  the  arm  in  any  work 
requiring  violent  extension,  within  six  months  from  the  time  of  the 
injury. 

Prognosis. — The  prognosis  depends  on  the  severity  of  the  injury 
and  the  efficiency  of  the  treatment.  In  the  uncomplicated  case, 
with  little  or  no  separation  of  the  fragments,  perfect  restoration 
of  function  should  follow  non-operative  treatment.  Recovery  with 
fibrous  union  may  or  may  not  be  accompanied  by  a  useful  elbow. 
If  the  fibrous  tissue  is  short  and  thick,  function  will,  as  a  rule,  be 
good.  If  it  is  thin  and  stretches  with  use  the  power  of  the  triceps 
will  be  lessened  or  lost  and  extension  incomplete.  Severe  traumatic 
reaction  and  prolonged  immobilization  of  the  elbow  render  the 
prognosis  worse,  since  they  are  productive  of  joint  adhesions.  Ap- 
proximation of  the  fragments  by  internal  fixation  and  early  pas- 
sive motion  are  usually  followed  by  complete  restoration  of 
function.  It  is  of  course  possible  to  have  perfect  function  with 
fibrous  union,  while  on  the  other  hand  loss  of  function  may  be 
pronounced  even  when  the  anatomical  result  is  perfect.  The  larg- 
est percentage  of  perfect  results,  however,  will  be  found  in  the 
cases  showing  the  most  perfect  reduction,  other  things  being  ecpial. 
In  compound  cases  the  prognosis  depends  largely  on  whether  or 
not  the  joint  becomes  infected.  (See  "Treatment  of  Compound 
Fractures  and  Luxations,"  page  789.) 


CHAPTER  XV. 

FRACTURES  OF  THE  UPPER  END  OF  THE  RADHJS. 

Surgical  Anatomy. — The  sections  on  ' '  Surgical  Anatomy ' '  under 
the  headings  of  "Fractures  of  the  Lower  End  of  the  Humerus," 
"Dislocations  of  the  Elbow"  and  "Dislocations  of  the  Head  of  the 
Radius"  apply  in  a  large  measure  in  fractures  of  the  upper  end 
of  the  radius.  The  head  of  the  bone  is  surrounded  by  the  orbicu- 
lar ligament,  except  where  the  latter  comes  in  contact  with  the 
lesser  sigmoid  cavity  of  the  ulna.     The  supinator  brevis  is  attached 


Fig.   262. 


Fig.   261. — Fracture   of    head    and    neck   of   radius. 
Fig.    262. — Comminuted  fracture  of  liead  of  radius. 

to  the  shaft  and  extends  upward  onto  and  almost  completely  sur- 
rounds the  neck  of  the  bone.  The  biceps  is  attached  to  the  pos- 
terior half  of  the  tuberosity  and  acts  as  a  supinator  of  the  forearm 
as  well  as  producing  flexion.  A  bursa  is  interposed  between  the 
tendon  of  this  muscle  and  the  anterior  half  of  the  tuberosity.  The 
interior  of  the  head  of  the  radius  is  composed  of  a  fine  meshed 
cancellous  tissue  which  is  covered  by  a  layer  of  compact  bone. 
The  surface  compact  tissue  is  heaviest  on  the  top  of  the  head.  The 
circumference  of  the  head,  coming  in  contact  with  the  orbicular 

197 


198  FRACTl'KES    AND    DISLOCATIONS 

ligaiueiit,  is  covered  by  only  a  very  tliiii  layer  of  compact  bone. 
That  found  on  the  surface  of  the  neck  is  a  little  heavier.  The 
tuberosity  is  not  a  heavy,  solid  prominence  of  compact  tissue  but 
is  composed  only  of  a  thick  crust  of  compact  bone,  the  interior 
being  made  up  of  a  wide  meshed  cancellous  tissue. 

The  upper  epiphysis  of  the  radius  consists  of  a  scale  of  bone 
corresponding  to  the  superior  articular  surface.  When  viewed 
laterally  under  the  X-ray  it  appears  as  a  line,  throwing  much  the 
same  shadow  as  would  a  coin  seen  on  edge.     This  epiphysis  begins 


Fig.   263. — Fracture  of   head  and   neck  of  radius. 

to  ossify  in  the  fifth  year,  and  joins  the  shaft  during  the  seven- 
teenth or  eighteenth  year. 

Fracture  of  the  upper  end  of  the  radius  is  rare.  The  head  may 
be  broken  as  a  complication  of  luxations,  b}^  violence  transmitted 
in  the  long  axis  of  the  shaft  (such  as  sustained  in  falls  on  the 
hand)  and  by  direct  trauma.  The  fracture  may  consist  of  a  small 
fragment  detached  from  the  articular  surface  or  the  entire  head 
may  be  extensively  comminuted.  Impaction  of  the  neck  into  the 
head  is  not  an  uncommon  type  of  injury.  When  this  occurs  im- 
paction is  usually  greater  on  one  side  of  the  bone  than  on  the 
other,  so  the  head  is  no  longer  "true"  when  the  shaft  is  rotated. 


FRACTURES    OF    UPPER   END    OF    RADIUS 


199 

A  verti- 


Fractnres  of  the  neck  are  usually  transverse  or  nearly  so 
cal  fracture  may  exist  passing;  through  both  head  and  neck. 

Fractures  of  the  upper  end  of  the  radius  are,  as  a  rule,  accom- 
panied by  only  slight  deformity,   if   any,   and   almost  invariably 


Fig.   264. — Fractiire  of  head  of  radius. 


W 


Fig.    2G5. — Fracture   of   head 
Head  "off  center." 


Xeik   iif   Ijdiu-   has  been   impacted   into   head. 


exist  as  complications  of  dislocations  of  the  elbow  or  radial  head 
alone,  or  of  fracture  of  the  lower  end  of  the  humerus  or  of  the 
ulna.  As  an  isolated  injury  they  are  unusual  though  by  no  means 
as  rare  as  supposed  prior  to  the  advent  of  the  X-ra3^ 

Symptoms. — Fracture  of  the  head  of  the  radius  alone  is  often 
productive  of  very  few  symptoms,  and  if  not  thoroughly  examined 
the  condition  may  be  overlooked  and  treated  as  a  sprain.  Local 
pain  and  swelling  are  present  over  the  head  of  the  bone.  The 
swelling  may  extend  halfway  down  the  outer  aspect  of  the  forearm 


200  FRACTURES   AND   DISLOCATIONS 

and  local  spasm  of  the  muselcs  in  lliis  region  is  almost  invariably 
j)resent.  Snpination  and  i)i-onation  are  usually  possi])le  but  this 
rotary  action,  of  the  I'oi'earm  may  he  restricted  through  spasm  and 
pain,  or  by  the  head  of  the  bone  being-  "otf  center."  If  a  frag- 
ment becomes  displaeed  into  the  joint  it  may  block  either  flexion 
or  extension  of  the  elbow. 

It  may  be  possible  to  detect  crepitus  by  direct  manipulation  and 
in  some  cases  a  fragment  may  be  felt  and  moved.  Crepitus  is  most 
commonly  elicited  by  supinating  and  pronating  the  forearm  while 
the  fingers  of  the  opposite  hand  palpate  the  head.  The  head  of 
the  bone  may  or  may  not  rotate  with  the  shaft  during  this  manipu- 
lation, depending  on  whether  or  not  the  fractured  surfaces  are 
firmly  engaged.  It  is  impossible  to  detect  crepitus  in  impacted 
eases.  Failure  of  the  head  to  rotate  with  the  shaft  is  conclusive 
when  present,  but  it  is  not  at  all  uncommon  to  find  the  head  ro- 
tating with  the  shaft  in  the  presence  of  fracture  of  the  head  or 
neck.  When  the  fractured  surfaces  are  not  engaged  the  biceps 
may  pull  the  upper  end  of  the  lower  fragment  forward  and  the 
resulting  change  in  the  axis  of  the  radial  side  of  the  forearm  may 
be  apparent.  This  forward  displacement  by  the  biceps  usually  hin- 
ders flexion  until  the  deformity  is  corrected. 

Diagnosis. — The  diagnosis  of  fracture  of  the  upper  end  of  the 
radius  may  be  very  easy  or  cjuite  difficult,  depending  on  the  symp- 
toms. If  the  parts  are  carefully  examined  it  will  usually  be  pos- 
sible to  determine  the  nature  of  the  injury  by  the  symptoms  just 
described,  but  in  some  cases  (especially  well  muscled  persons  and 
instances  in  which  the  swelling  is  pronounced)  a  Rontgenogram 
may  be  necessary  to  arrive  at  a  diagnosis.  Behind  the  external 
condyle  of  the  humerus  and  head  of  the  radius,  and  internal  to 
the  extensor  tendons  arising  from  the  epicondyle,  is  a  depression 
or  dimple  which  affords  ready  access  in  palpating  these  bony  parts. 
A  slight  transverse  depression  between  the  capitellum  and  radial 
head  may  be  felt  and  the  radius  should  be  distinguished  from  the 
humerus.  The  surgeon  should  not  make  the  mistake  of  palpating 
the  external  condyle  to  determine  rotation  of  the  radial  head. 
Such  a  mistake  would  not  seem  probable  yet  the  author  has  seen 
it  made  more  than  once.  The  X-ray  should  be  used  if  there  is  the 
least  doubt  as  to  the  nature  of  the  condition. 

Treatment. — The  management  of  these  cases  depends  on  the 
nature  of  the  fracture,  the  displacement  of  the  fragments  and  the 


FRACTURES    OK    III^I'ER    END    OE    RADIUS 


201 


association  of  other  lesions.  When  the  fracture  is  confiiicd  to 
the  head,  the  orbicular  ligament,  if  not  ruptured,  will  usually  pre- 
vent displacement  of  the  main  fragments,  though  a  portion  of  the 
head  may  escape  into  the  joint  and  require  removal.  As  a  rule, 
hovi^ever,  fracture  of  the  upper  end  of  the  radius  calls  for  little 
aside  from  immobilization  of  the  forearm,  which  is  well  accom- 
plished by  an  internal  right  angle  splint.  If  the  head  is  badly 
comminuted  it  may  be  advisable  to  remove  the  fragments,  round 
up  the  end  of  the  shaft  and  secure  it  in  place  by  suturing  the 


Figs.  266  and  267. — Loss  of  carrying  angl«  and  gun-stock  deformity  the  result  of 
fracture  of  both  bones  below  the  elbow.  Palpation  in  this  case  shows  the  liumeral 
condyles  and  olecranon  to  be  in  normal  relation.  Loss  of  carrying  angle  and  gun- 
stock  deformity   are  usually  the  result  of  fracture  of  the  lower  end  of   the  humerus. 

orbicular  ligament  and  other  adjacent  fibrous  tissue  over  it.  When 
obstruction  to  flexion  or  extension  is  caused  by  a  detached  frag- 
ment of  the  head  it  should  be  removed.  When  the  fracture  is 
below  the  head,  and  the  shaft  is  displaced  forward  by  the  action 
of  the  biceps,  the  splint  should  be  so  padded  that  pressure  will  be 
made  in  a  backward  direction  on  the  upper  end  of  the  lower  frag- 
ment. The  nse  of  pads  and  the  acutely  flexed  position  should  never 
be  employed  at  the  same  time.  The  use  of  padding  in  the  bend 
of  the  elbow  with  the  forearm  in  acute  flexion,  may  give  rise  to 


202  FRACTURES   AND   DISLOCATIONS 

st'rious  (lisl  lU'liaiift'S  of  tlic  circuhitioii  ;iii(l  in  llic  I'uiiction  of  the 
median  iifrve.  WIumi  the  fracture  is  Ix'low  tlie  oil)i(Mil;ii'  ligament 
acute  flexion  will  sometimes  afford  better  reduetion  than  the  use 
of  direct  pressure  and  the  right  angle  splint. 

Operative  Treatment. — Operation  may  be  indicated  for  tlie 
removal  of  a  loose  fragment  in  the  joint  or  to  apply  internal  fixa- 
tion to  a  fracture  of  the  neck  when  other  means  fail  to  maintain 
reduction.  The  open  method,  however,  is  seldom  called  for  in 
recent  cases.  When  a  loose  fragment  requires  removal  the  incision 
will  be  made  according  to  the  position  of  the  fragment.  For  other 
conditions  of  the  upper  end  of  the  radius,  requiring  operation  the 
posterior  longitudinal  incision  will  be  found  as  satisfactory  as  any. 
The  posterior  aspect  of  the  external  condyle  is  a  landmark  from 
which  the  incision  is  begun  and  carried  directly  downward  from 
two  to  three  inches;  after  the  skin  incision  is  made  the  muscles 
are  separated  and  the  upper  end  of  the  radius  exposed.  In  the 
presence  of  much  comminution  the  head  is  to  be  excised,  the  end 
of  the  shaft  rounded  up  and  sutured  in  place.  If  the  fracture  is 
somewhat  below  the  head  it  may  be  possible  to  so  place  a  loop  of 
wire  that  the  lower  fragment  will  be  bound  to  the  upper,  thus 
preventing  the  forward  displacement  due  to  the  pull  of  the  biceps. 
The  action  of  the  biceps  may  be  somewhat  further  relaxed  by  put- 
ting the  arm  up  in  greater  flexion  than  the  right  angle.  There  is 
little  that  can  be  done  with  fracture  of  the  head  aside  from  exci- 
sion, but  unless  the  comminution  is  great  it  is  best  to  wait  and 
determine  how  much  restriction  of  motion  will  be  present  when 
recovery  is  complete.  If  the  loss  of  function  is  then  pronounced 
a  secondary  operation  may  be  performed  and  the  head  removed. 
It  is  surprising  what  good  results  often  follow  complete  excision  of 
the  head.  Fractures  above  the  lower  border  of  the  orbicular  liga- 
ment seldom  unite,  regardless  of  the  treatment  employed,  so  there 
is  little  use  in  attempting  anything  in  the  way  of  operative  pro- 
cedure aside  from  excision  in  fractures  confined  to  the  head. 

After-Treatment. — The  after-treatment  of  fractures  of  the  upper 
end  of  the  radius,  like  other  fractures  about  the  elbow,  requires 
close  attention  to  avoid  constriction  when  swelling  sets  in,  and  as 
the  arm  decreases  in  size  during  the  subsidence  of  this  swelling 
the  dressings  should  be  tightened  daily  to  secure  proper  support 
and  immobilization.  In  children  union  will  be  present  at  the  end 
of  two  and  a  half  weeks,  but  is  not  firm  enough  at  this  time  to 


FRACTURES   OP   UPPER   END    OP   RADIUS  203 

permit  of  removal  of  all  dressings;  the  member  should  be  pro- 
tected and  supported  for  another  ten  to  fifteen  days  before  all 
splints  are  removed,  especially  if  the  child  is  active  and  not  easily 
controlled.  In  adults  the  parts  should  be  immobilized  for  a  period 
varying  from  three  to  five  w^eeks  according  to  the  age  of  the 
patient.  If  the  fracture  is  confined  to  the  head  union  cannot  be 
expected,  regardless  of  the  period  of  immobilization,  and  the  most 
important  element  in  the  after-treatment  is  then  the  early  insti- 
tution of  passive  motion  to  preserve  the  rotary  action  of  the  fore- 
arm. Passive  supination  and  pronation  should  be  begun  as  early 
as  the  end  of  the  first  week  or  ten  days  unless  the  traumatic  reaction 
persists.  When  the  fracture  is  of  the  neck  passive  motion  should 
be  delayed  until  union  is  firm  enough  to  v^^ithstand  manipulation. 
Prognosis. — The  outlook  depends  on  the  nature  of  the  fracture 
and  the  treatment  followed.  In  extensive  comminution  of  the 
head  there  is  likely  to  be  pronounced  loss  of  supination  and  pro- 
nation of  the  forearm  although  the  rotary  action  of  the  forearm 
is  usually  restored  with  operation  and  excision.  Perfect  function 
should  follow  fracture  of  the  neck  if  the  fragments  unite  in  ap- 
proximation ;  if  there  is  deformity  following  recovery  the  rotary 
action  of  the  forearm  may  be  seriously  impaired. 


CHAPTER  XVI. 

FRACTURES  OP  THE  RADIAL  AND  ULNAR  SHAFTS. 

Surgical  Anatomy. — The  shafts  of  the  bones  of  the  forearm  may 
he  broken  toycther,  or  either  bone  may  be  broken  separately.  It 
is  more  common  to  see  both  bones  broken  than  to  find  a  fracture 
of  either  bone  as  an  isolated  injury.  Fracture  of  the  radius  alone 
is  often  the  result  of  indirect  violence ;  the  lower  end  of  the  radius 


Fig.    268. — Section    of    radius    sliowing    Ji.-^p:i.'5ition    of    compaot    and    cancellous    tissue. 


Fig.   269. — Section    of    ulna    showing    disijosition 
O.,  Olecranon;   C,  Coronoid. 


iiliact     and    cancellous    tissue. 


supports  the  carpus  and  violence  sustained  by  the  hand  is  trans- 
mitted to  this  bone  rather  than  the  ulna.  P'racture  of  the  shaft 
of  the  ulna  is  usually  the  result  of  direct  violence;  the  posterior 
border  is  subcutaneous  throughout  and  is  particularly  exposed  to 
injury  in  falls  on  the  back  of  the  forearm  and  in  warding  blows 

204 


FRACTURES   OF   RADIAL   AND   ULNAR   SHAFTS  205 

from  the  head.  When  both  bones  are  broken  the  cause  may  be 
either  direct  or  indirect  violence.  Fracture  of  the  bones  of  the 
forearm  is  a  particularly  common  accident  in  childhood.  When 
the  shaft  of  either  bone  is  broken  alone  the  deformity  is,  as  a  rule, 
not  pronounced  since  the  opposite  shaft  acts  as  a  splint  in  prevent- 
ing displacement. 

The  various  deformities  accompanying  fractures  of  the  radial 
and  ulnar  shafts  depend  on  the  nature  and  direction  of  the  causa- 
tive trauma  and  the  different  muscles  attached  to  the  bones.  In 
speaking  of  the  deformities  due  to  muscular  action  in  different 
regions  of  the  forearm  it  will  be  understood  that  they  obtain  only 
when  the  serrated  fractured  surfaces  are  not  so  engaged  as  to  pre- 
vent displacement.  Fracture  of  the  radial  shaft,  below  the  tuber- 
osity and  above  the  insertion  of  the  pronator  radii  teres,  is  likely 
to  be  accompanied  by  supination  of  the  upper  fragment  and  pro- 
nation of  the  lower.  The  biceps  and  supinator  brevis  produce 
supination  of  the  upper  fragment,  and  the  first  named  muscle  will 
also  tend  to  displace  the  lower  end  forward.  The  lower  fragment 
will  occupy  a  position  of  pronation  due  to  the  action  of  the  pro- 
nator radii  teres  and  the  pronator  quadratus,  and  the  upper  end 
of  the  lower  fragment  will  usually  be  displaced  toward  the  ulnar 
shaft  through  the  action  of  these  two  muscles.  When  the  fracture 
is  below  the  insertion  of  the  pronator  radii  teres  both  fractured 
ends  will  be  displaced  toward  the  radius  by  the  pull  of  these  two 
pronators.  In  fractures  of  the  shaft  of  the  ulna  the  upper  end 
of  the  lower  fragment  may  be  displaced  toward  the  radius  by  the 
action  of  the  pronator  quadratus;  the  nearer  the  fracture  is  situ- 
ated to  the  upper  border  of  this  muscle  the  more  pronounced  the 
action. 

The  relation  of  the  bones  during  supination  and  pronation  is  of 
importance  in  treating  fractures  of  the  forearm.  In  supination 
the  interosseous  membrane  is  taut  and  the  two  bones  in  the  same 
plane.  As  the  forearm  is  carried  into  pronation  the  lower  end  of 
the  radius  describes  an  arc  about  the  lower  end  of  the  ulna,  and 
when  pronation  is  complete  the  radial  shaft  crosses  the  shaft  of 
the  ulna  obliquely.  In  complete  pronation  the  shafts  of  the  two 
bones  are  nearer  than  in  any  other  position.  The  obliquity  of  the 
fibres  of  the  interosseous  membrane  is  such  that  with  upward 
longitudinal  stress  on  the  radius  a  portion  of  the  strain  is  imparted 
to  the  ulna.     The  oblique  ligament  is  composed  of  fibres  passing 


206 


FRACTURES   AND    DISLOCATIONS 


in  the  opposite  direction  and  tends  to  prevent  the  radius  being 
pulled  away  from  the  humerus.  The  sliafts  of  ])oth  hones  are 
composed  of  heavy  tubes  of  compact  tissue,  and  the  fractures  seen 
in  this  region  are  tho.se  common  to  the  shafts  of  otlicr  long  bones. 
They  may  be  transverse,  oblique,  spiral,  eoiinninuted,  nmltiple, 
green-stick,  subperiosteal,  etc.  Divergence  of  either  the  upper  or 
lower  pair  of  fragments  occurs  onl^'  with  rupture  of  the  inter- 
osseous membrane  and  is  rare.  In  unusual  cases  the  ends  of  all 
four  fragments  may  be  close  together  and  embraced  by  one  callus. 
In  other  instances  angular  deformity  of  the  fragments  of  one  bone 
toward  the  opposite  shaft  may  be  accompanied  by  a  large  callus 
which  interferes  with  the  rotary  action  of  the  forearm.  When 
both  bones  are  fractured  the  break  in  thi'  ulna  is  usually  at  a  slightly 


Fig.  27(1. — Fiactuie  of  botli  luiues  of  the  forearm  tlie  result  of  direct  violence.  Hand 
displaced  dorsally  ami  slightly  to  the  radial  side.  Fracture  of  ulna  transverse  and  de- 
formity purely  angular.  Fracture  of  radius  is  slightly  oblique  so  that  there  is  an  ele- 
ment of  overriding  as  well  as  angularity  in  the  displacement  of  this  bone.  The  slight 
overriding  of  the  radial  fragments  caiises  the  hand  to  he  displaced  a  little  to  the  radial 
side  as  well  as  backward.  Arrow  points  to  wound  produced  by  lower  end  of  upper 
fragment  of  radius  penetrating  the  skin.  AnguLar  deformity  corrected  at  once.  Radius 
could  not  be  perfectly  reduced  and  persisted  in  slipping  out  of  place.  Operation  about 
one  week  following  injury;  radius  secured  in  reduction  by  circular  wire,  which  is  bad 
practice  in  compound  cases  before  the  wound  has  healed.  (See  "Operative  Treatment 
of   Compound   Fractures    and   Lu.xations.")      Ultimate   recovery   perfect. 


higher  level.  In  rare  instances  the  fractures  may  be  situated  at 
opposite  ends  of  the  shafts.  INIuscular  action  is  known  to  have  pro- 
duced fracture  of  the  bones  of  the  forearm,  but  is  extremely  rare. 
Symptoms. — Tlie  symptoms  accompanying  fractures  of  the  bones 
of  the  forearm  vary  with  the  region  of  the  fractures,  the  age  of 
the  jnitient,  and  whether  or  not  both  l)ones  are  broken.  In  frac- 
tures of  the  radud  shaft  the  deformity  is  usually  not  pronounced 
and  may  be  quite  difficult  to  recognize.  If  one  or  both  fragments 
are  displaced  toward  the  ulna  the  radial  side  of  the  forearm  ma}'- 


FRACTURES   OP   RADIAL   AND    ULNAR    SHAFTS 


207 


Fig.  271. — Another  view  of  same  ease  sliowicg  dorsal  surfiioe  of  fureaiiii.  Note 
the  transverse  groove  indicated  by  the  arrow.  This  groove  indicates  to  some  extent  the 
relative  levels  of  the  two  fractures.  These  photograishs  were  taken  immediately  follow- 
ing the  accident  and  just  prior  to  reduction. 


Fig.    272. — Autero-poslerior   view  of   fracture  uf   radiu.s   and  ulna   after  reduction  has 
been   attempted. 


Fig.  273. — Lateral  view  of  same  case  showing  deformity  in  radial  fracture.  The 
fracture  in  the  radius  is  slightly  oblique  and  persists  in  slipping  out  of  position  after 
reduction.  On  this  account  operation  was  performed  and  reduction  secured  by  a  cir- 
cular wire. 


208 


FRACTURES   AND    DISLOCATIONS 


Pig.  274. — Autcro-ijostfriur  view  of  same  case  some  weeks  after  operation.  Circu- 
lar wire  was  used  and  infection  followed.  The  case  wii.s  compound  from  the  first.  The 
placing  of  foreign  materiaKs,  especially  of  the  non-absorbable  type,  is  to  be  condemned  in 
operating  on  compound  fractures.  Some  absorption  of  bone  has  taken  place  under  the 
wire,  and  as  a  result  slight  recurrence  of  deformity.  Wire  removed — perfect  recovery 
followed. 


Pig.   275. — Lateral  view  of  same  case. 


Fig.  27fi. — Fracnirc  of  both  linno  <if  the  f.in^ann  with  the  usual  backward  dis- 
placement of  the  hand.  Photograph  about  one  and  a  half  hours  following  the  accident. 
Angular  deformity  pronounced  but  there  is  no  overriding  of  the  fragments. 


FRACTURES   OF   RADIAL   AND   ULNAR   SHAFTS 


209 


show  an  abnormal  concavity  as  illustrated  in  Fig.  287.  In  any 
case  there  will  be  pain  in  the  region  of  the  fracture,  tenderness  on 
pressure  and  manipulation,  swelling  and  more  or  less  complete  loss 
of  function.  If  the  fracture  is  in  the  lower  third  of  the  radius 
and    the    upper    end    of    the    lower    fragment    displaced    toward 


li 

JM 

■ 

Ik'l 

^H 

H 

BS  •;^^«^--                ^^1 

H[ 

1 

"V                         '         '^^ 

s 

V\o 


Figs.  277  and  278. — Fracture  of  both  bones  of  the  forearm  with  the  usual  deform- 
ity. Fractures  at  about  same  level.  Pictures  taken  a  few  minutes  following  the  acci- 
dent. 

the  ulna,  the  radial  styloid  will  be  correspondingly  raised  and  the 
lower  articular  surface  changed  in  position.  Overriding  of  the 
fragments  and  shortening,  however,  will  be  absent  unless  the  head 
of  the  ulna  is  luxated  or  the  ulnar  shaft  fractured.  During  supi- 
nation and  pronation  of  the  forearm  the  radial  head  will,  in  most 


210 


FHArTL'RES    AND    DISLOCATIONS 


cases,  fail  to  follow  tlu^  i-otation  of  the  sliaPt.  Ci-opitus  can,  as  a 
rule,  be  elicittnl  if  the  I'l-aginonts  arc  iicaspcd  aliovc  and  l)clow  the 
scat  of  the  fractui'i'  and  iitanipulalcd.  If  the  foi'cMrni  l)i'  placed  in 
snpin;ition  and  lii'iiily  held  in  this  position,  while  l;itci';d  prcssui'c 
is  exerted  on  llie  shafts  of  tlio  radins  and  ulna   1)\'  the  tlnnnb  and 


Fig.  2'J9. — Same  case  showing  reduction  of  deformity.  Arrow  1  indicates  the  di 
rection  of  pressure  made  by  the  snra:eon's  right  hand.  Arrow  2  indicates  the  course  to 
Ve  taken  by  the  distal  fragment  during  reduction.  Arrow  3  traction  made  on  the  lower 
fragment  while  it   is  being  brought  back  into  jjosition. 


Fig.  280. — Shows  ventral  view  of  same  case.  Ventral  prominence  is  evident  but 
it  will  be  noted  that  there  is  no  displacement  of  the  hand  to  either  radial  or  ulnar 
sides. 


forefinger  of  the  opposite  hand,  the  normal  lateral  spring  of  the 
radial  shaft  will  be  found  wanting.  In  children  the  fracture  may 
be  of  the  green-stick  or  subperiosteal  type  and  accordingly  crepi- 
tus and  mobility  will  be  absent.  The  shaft,  however,  usually  shows 
more  or  less  bowing  in  a  given  direction  and  the  region  of  fracture 


FRACTURES   OF    RADTAIj   AND    ULNAR    SHAFTS 


211 


will  be  swollen,  tender  and  painful.  Lateral  pressure  on  the  radial 
shaft  will  usually  show  that  the  normal  lateral  sprino'  of  the  shaft  is 
increased  and  will  produce  pain  at  the  seat  of  i'raeture  rather  than 
at  the  point  of  pressure. 

Fracture  of  the  ulnar  sltaft  alone  is  productive   of  s^nnptoms 
simihir  to  isolated   fiacture   of   the   radial    shaft   except   tliat   the 


Fig.   281. 


Fig.   232. 


Figs.   281   and   282. — Lateral  and  antero-posterior  views  of  ease  shown  in  Figs.  277, 
278,  279  and  280,  after  reduction. 


swelling',  pain,  tenderness,  etc.,  are  situated  on  the  inner  side  of 
the  forearm  rather  than  on  the  radial  side.  Displacement  is  rarely 
pronounced  as  long  as  the  radius  remains  intact.  The  posterior 
border  of  the  ulnar  shaft  is  subcutaneous  throughout  and  unless 
the  swelling  is  extreme  it  will  be  possible  to  determine  the  position 
of  the  fracture  by  palpation.  The  lower  fragment  is  often  displaced 
toward  the  radius.  Shortening  does  not  take  place  because  the 
radius  acts  as  a  splint  and  maintains  the  length  of  the  forearm. 
Use  of  the  forearm  is  painful  and  lateral  pressure  on  the  shaft 
excites  pain  at  the  seat  of  fracture  and  ]5ot  at  the  point  of  pressure. 


rU'F.S     \\n    DISLOCATIONS 


Figs.  283  and  284. — Same  case  as  shown  iu  Pigs.  278  and  279  after  reduction  has 
been  accomplished  and  splints  applied.  It  will  be  noted  that  the  posterior  splint  may 
be  removed  for  examination  of  the  forearm  without  disturbing  the  fi.xation  of  the  fore- 
arm which  is  still  firmly  bound  to  anterior  splint.  Yucca  board  has  been  used  in  mak- 
ing these  splints  and  serves  the  purpose  admirably  but  should  not  be  used  unless  one  is 
experienced  in  the  treatment  of  these  eases  and  the  forearm  is  closely  watched  for 
syniptums   of   strangulation.      (See   text.) 


Fig.    286. 
Figs.    285    and    286. — Same   case   at   the   time   the   splints   were   removed. 


FRACTURES   OP    RADIAT.    AND    ULNAR    SHAFTS 


213 


Fig.   283. 


Figs.  287  and  288. — Slightly  oblique  fracture  of  radius  about  three  inches  above 
wrist.  Lower  fragment  displaced  toward  ulna.  Note  the  increased  curve  in  the  radial 
side  of  forearm  and  the  slight  displacement  of  the  hand  to  the  radial  side.  (Comparo 
with  Figs.  290  and  291.)  Reduction  difficult  as  lower  fragment  persisted  in  slipping 
out  of  place.  Operation  performed  after  two  attempts  at  reduction.  Fragments  wired. 
Recovery  perfect.      (See  X-rays  shown  in  Figs.  292  to  297.) 


Figs.  289  and  290. — Two  views  of  the  opposite  arm  taken  for  comparisou.  Note 
the  normal  curve  on  the  radial  surface  of  the  forearm  as  compared  with  that  seen  in 
Figs.  288  and  289. 


214 


PRArTrRr-:s  and  nisT-ocATioNS 


Figs.    291    :nul    LIIll!. — AiitiTd-postcri.ii-    and    l:itiT:il    views    of    I'lMcturc    iif    rjidius    with 
recurrence  of  dcfonniiy   ;it'tcr  rodiictioii.      S:iiiic  case  as   sIkiwii    in    b'ins.    -'""T   and  288. 


[ 

-^:mm 

^^,,„*j«y#^. 

1 

i 

1'. 

l*i«rT»ii  •.-»  >    ..t 

J 

Figs.   293   and   294. — Sliows   same    case   after    a    second    reduction    and   recurrence   of 
deformity. 


FRAf!TlIKr;S    OF    RADIAT.    AND    lILNAIt    SKAK'I'S 


215 


The  heavy  aponeurosis  attached  to  the  posterior  border  tends  to 
prevent  lateral  displacement. 


Fiff.   296. 


Figs.   295   and   296. — Same  case  after  operation  sliowing  correction  of  deformity  and 
securing  of  fragments  in  position  by  means  of  a  loop  of  silver  wire. 


Fig.  297. — Fracture  of  botli  bones  of  the  right  forearm  in  a  child  two  and  a  half 
years  of  age.  The  deformity  in  this  case  is  unusual  in  that  the  forearm  is  bowed  back- 
ward.     Photograph  taken  before  reduction  and  about  one  hour  following  accident. 

When  ioth  tones  are  broken  the  deformity  is  usually  pronounced 
and  may  be  of  either  the  overriding  or  angular  type.  The  bones 
of  the  forearm  may  be  displaced  in  any  direction  but  the  common 


216 


FRACTURES   AND   DISLOCATIONS 


deformity  consists  in  a  l)a<-k\vai-(l  lu'iidiiiii  of  the  forearm; — tlie 
dorsal  surface  of  the  forearm  forms  an  obtuse  angh^  while  the 
ventral  surface  forms  the  salient  anule.     A  much  less  eonnnon  dis- 


Fig.   298. 


Fig.    299. 

Figs.  298  and  299. — Fractui-e  of  both  bones  of  tbo  forearm  seen  from  radia*  and 
ulnar  sides.  Tlie  fraetures  are  so  low  that  the  condition  is  likely  to  be  ciinfounded  with 
Colles'  fracture.  It  will  be  noted,  however,  that  the  ulnar  deformit.v  begins  at  a 
higher  level  in  this  case  than  it  does  in  Colles'  fracture.  Tlie  level  of  the  ulnar  fracture 
is  not  as  apparent  by  inspection  as  it  is  when  palpated.  The  lower  ulnar  fragment  may 
be  felt  displaced  backward. 


Fig.  300. — Fracture  of  both  bones  of  the  forearm  near  the  wrist.  Condition  closely 
resembles  Colles'  fracture.  Inspection  and  pali)ation  of  the  ulnar  side  of  the  wrist  dis- 
closes the  break  in  the  ulna  and  the  backward  displacement  of  the  lower  fragment. 

placement  is  that  shown  in  Fig.  297  in  which  the  forearm  is  bent 
forward  instead  of  backward.  Forward  or  backward  displacement 
may  take  place  and  be  pronounced  without  any  element  of  over- 
riding in  either  bone.     When  however  the  hand  and  lower  part 


FRACTURKS    OP    RADIAL    AND    UI.NAR    STTAKTS 


217 


FiS.    £02. 


Fis't.    eoi    aiul    SO'^ — Fiaituve   (if   bcitli   bones   of   thr    fore  inn    a    r-h'jrt    distance   abjve 
tlie  wrist   willi  \ei\    slii;lit   detorniity.      Nole   llie   sliglit   backward   licnding  of  the   forearm. 


Fig.    303. — Upper    arrow    points    to    free    radial    styloid    (auomalous) .      Lower    arrow- 
points  to  fracture  of  the  shaft  of  the  radius. 


218 


FRACTURES   AND    DISI-OfATIONS 


of  the  forearm  are  displaced  to  either  the  radial  or  ulnar  side,  the 
bone  on  the  concave  side  of  the  forearm  will  nsually  show  over- 
riding deformity.  If  the  displacement  is  a  combination  of  antero- 
posterior and  lateral  (for  example,  if  the  hand  is  displaced 
backward  and  also  to  the  radial  side)  it  will  be  due  either  to  over- 
riding and  angular  deformity  of  the  shaft  on  the  concave  side  of 


^04. 


Fig.   305. 


Figs.  304  and  305. — Green-stick  fracture  of  the  ulna  in  a  child.  This  condition 
might  be  easily  overlooked  if  the  X-ray  had  not  been  employed.  Lateral  compression 
of  the  two  bones,  however,  showed  more  "spring"  than  normal  in  the  ulnar  shaft. 
(See  Fig.  307.)  Comparison  with  the  opposite  ulna  renders  recognition  of  the  condi- 
tion easier. 

the  forearm,  or  else  the  fractures  are  at  different  levels  and  the 
forearm  folds  back  diagonally.  The  nature  of  the  deformity  and 
the  crease  on  the  dorsal  surface  of  the  forearm  will  usually  indi- 
cate the  relative  levels  of  the  two  fractures.  This  crease  represents 
the  apex  of  the  angle  of  displacement  and  when  the  fractures  are 
at  the  same  level  the  crease  will  run  transversely  across  the  back 
of  the  forearm.     When  the  fractures  are  at  different  levels  the 


FRACTURES   OF    RADIAL   AND    ULNAR    SHAFTS  219 

crease  will  be  more  or  less  obliquely  placed.  It  is  well  shown  in 
Figs.  271  and  277.  In  some  instances  the  fragments  of  both  bones 
will  show  only  overriding  deformity  with  thickening  of  the  fore- 
arm where  the  fragments  overlap.  This  thickening  is  often  diffi- 
cult to  distinguish  from  the  usual  swelling  at  the  site  of  fracture, 
but  the  accompanying  shortening  of  the  forearm  and  the  resultant 
flail-like  condition  will  disclose  the  nature  of  the  injury.  An  ex- 
cellent example  of  this  condition  is  shown  in  Figs.  313  and  314. 
The  loss  of  function  is  complete  when  both  bones  are  broken  and 
the  attitude  in  which  the  patient  supports  the  entire  length  of  the 
forearm  with  the  opposite  member  is  characteristic. 

In  "green-sticli"  fractures  of  the  forearm  there  is  more  or  less 
bowing  of  the  shafts  of  both  bones,  as  a  rule,  either  forward  or 
backward.  The  deformity  is  seldom  as  distinctly  angular  as  seen 
in  adults  but  presents  more  of  a  curved  effect.  The  condition  is 
not  flail-like  and  mobility  is  absent.  The  lateral  spring  of  both 
bones,  however,  is  usually  increased.  This  increase  in  spring  is 
particularly  noticeable  if  pressure  is  made  on  the  concave  side  of 
the  deformity.  The  symptoms  in  children  are  occasionally  quite 
mild,  producing  little  more  in  the  way  of  disability  than  would 
result  from  a  bad  sprain  or  bruising  of  the  forearm.  This  fact 
calls  attention  to  the  necessity  of  a  careful  examination  and  the 
use  of  the  X-ray  in  doubtful  cases  following  injury  of  the  forearm 
in  a  child. 

Diagnosis. — In  making  a  diagnosis  of  fracture  of  the  forearm  the 
parts  should  be  carefully  and  systematically  examined.  There  is 
much  which  can  be  learned  by  inspection  alone  since  the  majority 
of  fractures  in  this  region  are  accompanied  by  characteristic  de- 
formities, as  shown  in  the  accompanying  illustrations.  The  more 
the  surgeon  can  gather  by  inspection  the  less  there  will  remain 
to  be  determined  by  palpation  and  the  shorter  will  be  manipulation 
which  only  increases  the  damage  to  the  already  traumatized  so£t 
tissues.  The  deformities  shown  in  the  accompanying  illustrations 
are  not  exceptional  but  represent  the  average  run  of  cases,  and  a 
study  of  these  photographs  should  be  of  service  to  the  student  in 
enabling  him  to  recognize  these  conditions  with  the  least  possible 
disturbance  of  the  parts.  It  is  always  advisable  to  have  a  Ront- 
genogram  taken  of  the  case  to  determine  the  accuracy  of  reduction, 
if  not  for  the  purposes  of  establishing  a  diagnosis.  Theoretically 
an  X-ray  examination  is  of  great  value  before  reduction  is  at- 


220  FRACTURES   AND   DISLOCATIONS 

tempted,  hut  jirtu'ticilly  I  he  time  necessary  to  secure  such  an 
examination  often  reiHlcrs  it  inrxpcdicnt.  HMic  lon.ii'er  the  deform- 
ity exists  the  greater  the  .sufreiin^  and  the  more  i)rononneed  tlie 
secondary  traumatic  reaction.  It  is  therefore  iii(um1)ent  on  the 
surgeon  to  effect  reduction  at  tli(>  eai'liest  |)ossil)h'  moineiit  and  to 
k'arn   all   that    is    possihh'    \)y    iiispeet  ion    and    |»;d|»;ili<)n    het'oi'e   the 


Fig.    306. — Testing    the    .'^iJi'iiiy    in    the    Itones    of    the    I'oreiirni    li.\-    means    of    lateral 
pressure. 

fragnients  are  brought  back  into  alignment.  When  one  is  accus- 
tomed to  interpreting  these  deformities  a  successfid  reduction  will 
often  be  possible  before  the  X-ray  is  made,  while,  on  the  other 
hand,  if  these  physical  signs  are  neglected  a  secondary  manipula- 
tion will  usually  be  needed  after  the  X-ray  returns  are  available. 
Treatment. — Reduction  of  isolated  fractures  of  the  radius  may 
be  easy  or  difficult  according  to  the  nature  of  the  break  and  the 
displacement  present.  When  the  fracture  is  high,  the  anterior  dis- 
placing action  of  the  biceps  may  require  immobilization  in  a  posi- 
tion just  short  of  acute  flexion.  (See  Fig.  210  and  page  145  under 
Treatment  of  "Fractures  of  the  Lower  End  of  the  Humerus.") 
If  the  fracture  is  between  the  insertions  of  the  biceps  and  pronator 
radii  teres  the  condition  is  usually  best  treated  with  the  forearm 
in  a  position  of  semiflexion  and  complete  supination.  (See 
"Anatomy"  on  page  205.)  This  places  the  lower  fragment  in  a 
position  of  supination  to  correspond  to  the  upper  fragment  which 
has  been  snpinated  by  the  biceps  and  supinator  brevis.  If  the 
fracture  in  the  radius  is  low,  the  upper  end  of  the  lower  fragment 
may  be  displaced  toward  the  ulna;  strong  traction  on  the  wrist 


FRACTURES   OF    RADIAL   AND   ULNAR   SHAFTS  221 

with  adduction  of  the  hand  may  be  necessary  to  bring  the  lower 
fragment  back  into  alignment.  If  reduction  cannot  be  effected 
by  manipulation  operation  is  indicated.  "When  the  fracture  is 
high  the  elbow  should  be  immobilized,  and  when  near  the  wrist  it 
may  be  necessary  to  include  the  hand  in  the  splint.  The  splints 
to  be  used  and  the  precautions  to  be  observed  in  applying  them 
are  the  same  as  will  be  described  shortly  in  the  treatment  of  frac- 
tures of  the  shafts  of  both  bones  of  the  forearm.  In  instances  in 
which  the  serrations  are  coarse  there  may  be  difficulty  in  securing 
a  satisfactory  engagement.  Under  these  conditions  reduction  may 
sometimes  be  facilitated  by  temporarily  increasing  the  angular  de- 
formity while  attempting  to  engage  the  fractured  ends.  With  the 
ends  thus  engaged  the  angular  deformity  is  easily  corrected  since 
the  ulna  maintains  the  length  of  the  forearm. 

The  reduction  of  isolated  fractures  of  the  ulnar  shaft  is  ac- 
complished in  a  manner  similar  to  that  employed  in  fractures  of 
the  radial  shaft.  Keduction  is  usually  not  attended  by  much 
difficulty  as  long  as  overriding  of  the  fragments  is  prevented 
by  an  intact  radius.  Traction  on  the  hand  can  accomplish  noth- 
ing. Displacement  of  the  lower  fragment  toward  the  radius  is 
common  and  is  to  be  corrected  by  digital  pressure  between  the 
bones.  It  is  often  possible  to  secure  an  engagement  of  the  ser- 
rated ends  so  that  this  deformity  will  not  recur.  When  the  con- 
dition is  compound  it  should  be  treated  according  to  the  principles 
laid  down  under  the  heading  of  "The  Treatment  of  Compound 
Fractures  and  Luxations,"  on  page  789. 

Unfortunately  fracture  of  the  shafts  of  both  hones  of  the  fore- 
arm is  much  more  common  than  fracture  of  either  bone  separately 
and  the  condition  is  more  difficult  to  treat,  not  only  because  there 
are  two  bones  to  be  reduced  but  because  neither  bone  enjoys  the 
supporting  effect  of  the  other.  It  is  only  by  appreciating  the  dif- 
ferent types  of  deformity  and  what  they  indicate  that  one  is 
qualified  to  return  the  fragments  to  their  proper  positions  with 
the  greatest  accuracy  and  dispatch.  When  the  deformity  is  purely 
angular  and  the  fractures  approximately  transverse  there  will 
seldom  be  any  difficulty  in  effecting  reduction.  Wh(;n  however 
there  is  overriding  of  one  or  both  pairs  of  fragments  correction 
of  the  displacement  is  much  more  difficult.  The  overriding  de- 
formity should  be  reduced  before  the  angular  displacement  is 
corrected.     One  is  thus  enabled  to  secure  an  engagement  of  the 


222  FRACTURES    AXO    DISI.OCATIONS 

serrated  ends  before  the  fra.mneiits  are  bi-ou^lit  l)!U'k  iiilo  nlifiiinient. 
It  should  be  remembered  during  all  manipulations  that  tlic  shjivp 
serrated  ends  of  the  fragments  may  be  made  to  do  serious  injury 
to  the  soft  tissues.  AVheu  it  is  foiuul  ncccssiirx-  lo  in;ike  lateral 
pressure  on  a  fragment  the  force  should  be  ai)|ili((l  a  little  above 
or  below  the  seat  of  fracture,  as  the  case  may  be,  and  not  directly 
on  the  displaced  end.  Fracture  of  the  radius  between  the  i)iser- 
tions  of  the  biceps  and  pronator  radii  teres,  calls  for  innnobiliza- 
tion  of  the  forearm  in  the  supinated  position,  the  same  as  already 
mentioned  in  the  treatment  of  isolated  fractures  of  the  radial 
shaft.  AVhen  the  fragments  of  only  one  shaft  are  found  to  be 
overriding  (more  often  the  radius)  our  attention  may  be  confined 
almost  entirely  to  correcting  the  deformity  of  this  one  bone.  The 
lateral  displacement  is  first  reduced  and  then  the  angular  de- 
formity; the  opposite  bone  will  follow  provided  it  shows  only 
angular  displacement.  When  reduction  is  ditficult  or  the  patient 
nervous  and  hard  to  control  it  may  be  advisable  to  accomplish  re- 
duction under  anesthesia.  It  is  well  to  remember  that  children 
are  not  as  safe  subjects  for  anesthesia  as  adults  and  reduction 
in  many  cases  entails  only  an  instant  of  pain  if  properly  per- 
formed. In  reducing  green-stick  fractures  in  children  it  may  be 
possible  to  simply  correct  the  bowing  and  straighten  the  bone  but 
more  often  it  will  be  found  necessary  to  complete  the  fracture  by 
bending  the  shaft  in  the  direction  of  the  bowing  and  then  treat- 
ing the  condition  as  a  complete  fracture. 

If  the  surgeon  has  reason  to  anticipate  any  special  dit!iculty  in 
effecting  reduction  it  may  be  well  to  prepare  for  operation  before 
giving  the  anesthetic,  and  then  if  it  is  found  that  reduction  can- 
not be  accomplished  by  manipulation  he  is  ready  to  correct  the 
displacement  by  open  incision.  Thus  an  additional  anesthetic 
is  avoided,  time  is  saved  and  there  are  no  failures  to  be  explained. 

The  splints  employed  in  immobilization  of  fractures  of  the 
forearm  are  the  same  whether  one  or  both  bones  are  broken.  Flat 
anterior  and  posterior  splints  will  be  found  to  meet  the  require- 
ments in  the  largest  number  of  cases.  They  should  be  a  little 
broader  than  the  widest  portion  of  the  forearm  and  well  padded 
before  being  applied.  Light  quarter-inch  wood  will  answer  the 
purpose  well.  Pliable  wood  such  as  yucca  board  may  be  em- 
ployed but  should  be  used  with  the  greatest  caution  and  must  never 
be  bandaged  in  place  tightly  enough  to  force  it  to  conform  to  the 


FRACTTTRKS   OK    RADIATy    AND    TTT.NAR    STTAFTR 


223 


A  I'I'I.ICA'I'ION     OV    Sl'MNTS    'I'O    'rill':     KOKKAK.M. 


Fig.    307. — Fracture    of    liotli    Ikhips    of    tlie    forpiirm    jirior    to    reduction.      (See   Figs. 
385    and   38-6.) 


Fig-.    308. — Ventral    splint    apiilied    followina;   reduction    and    held   in    position    Ijy    two 
straps  of   adhesive — A.   and  B. 


Fig.   309. — Forearm  turned  so  that  thenar  "cut-out"  may  be  seen. 


Fig.    310. — Dorsal    splint    applied    and    held    in    position   by    two    additional    straps    of 
adhesive — C.  and  D. 


Fig.  311. — Bandaging  covering  both  splints.  When  the  forearm  is  broken  above  the 
middle  this  dressing  should  be  supplemented  by  an  internal  right  angle  splint.  (See 
Fig.   213.) 


224  FRACTIKES    AXn    DISLOCATIONS 

contour  of  the  forearm,  as  otherwise  eonstrietion  may  result.  The 
anterior  splint  should  extend  from  the  middle  of  the  palm  of  the 
hand  to  a  point  just  lielow  the  bend  of  the  elbow  when  the  fore- 
arm is  semirie'xed.  The  radial  side  of  the  lower  end  of  tlie  splint 
should  be  eut  away  to  clear  the  thenar  eminence  as  shown  in  Fi^-. 
309.  The  cotton  padding  should  be  thicker  jiist  above  the  wrist 
and  opposite  the  palm  of  the  hand.  The  posterior  si)lint  should 
extend  from  the  metacarpo-phalangeal  knuckles  to  a  point  a  short 
distance  below  the  elbow.  The  forearm  nnist  not  be  bandaged 
before  the  splints  are  applied  as  the  circulation  may  thus  be  in- 
terfered with.  One  splint  is  put  in  place  (usually  the  palmar) 
and  secured  with  two  strips  of  adhesive  as  shown  in  Fig.  308 
and  the  parts  examined  to  see  that  reduction  is  maintained.  The 
second  splint  is  then  ai)i)lied  and  secured  with  strips  of  adhesive 


Fig.  312. — Shows  same  dressing  opened  up  for  inspection  during  the  after-treat- 
ment. Straps  C.  and  D.  have  been  cut  and  dorsal  splint  turned  back,  thus  allowing 
inspection  and  palpation  of  the  forearm  while  it  is  still  secured  to  the  ventral  splint. 
(See  aJso  Figs.  283   and  284.) 

which  encircle  both  splints.  The  splints  should  be  loosely  ban- 
daged, especially  when  the  dressing  is  first  applied.  Gangrene 
of  the  forearm  or  Volkmann's  contracture  may  follow  too  tight 
bandaging,  and  the  surgeon  cannot  alwaj^s  depend  on  the  sensa- 
tions of  the  patient  to  give  warning  that  damage  is  being  done. 
Gangrene  is  known  to  have  occurred  without  attracting  the  pa- 
tient's attention.  Phlegmonous  inflammation  is  not  uncommon, 
and  pus  developing  within  the  tissues  may  cause  extensive  dam- 
age by  burrowing.  It  must  be  remembered  in  this  connection  that 
a  bandage  may  be  of  the  proper  snugness  at  the  time  of  applica- 
tion and  yet  a  few  hours  of  swelling  may  result  in  dangerous 
strangulation  of  the  forearm.  Any  form  of  splint  which  is  curved 
to  conform  to  the  surface  of  the  forearm,  or  a  rolled  bandage 
applied  to  the  forearm  before  flat  splints  are  put  in  place,  is  more 
likel}"  to  produce  strangulation  than  is  the  simple  flat  splint. 
Splints  making  pressure  between   the  bones   of   the    forearm   to 


FRACTURES   OP    RADIAL    AND    ULNAR    SHAFTS  225 

prevent  approximation  of  the  fragments  across  the  interosseous 
space  are  dangerous  and  should  never  be  used.  If  1Ih'  fracturf^  or 
fractures  are  in  the  upper  half  of  the  foreai-m  an  intcr-iial  or 
external  right  angle  splint  should  be  used  in  addition  to  the  flat 
splints  employed  in  immobilijcing  the  forearm.  If  the  break  is 
near  the  elbow  it  will  be  impossible  to  secure  proper  fixation  with- 
out immobilizing  the  elbow.  The  thumb  and  fingers  shoubl  Ix-  left 
exposed  in  all  cases  so  that  the  condition  of  the  circulation  may  be 
known  without  removing  the   dressings. 

The  secondary  traumatic  reaction  is  often  pronounced  in  frac- 
tures of  the  forearm,  and  must  be  taken  into  consideration  in  the 
treatment  of  fractures  in  this  region.  If  the  trauma  to  the  soft 
tissues  is  great  it  may  be  best  to  defer  the  application  of  splints 
until  the  swelling  is  decreasing  and  under  control.  It  is  often 
possible  to  foretell  approximately  the  degree  of  swelling  which  will 
follow,  by  the  extent  of  bruising  of  the  tissues  of  the  forearm, 
and  when  the  surgeon  has  reason  to  anticipate  a  severe  reaction 
the  case  should  be  treated  for  the  first  few  days  along  the  follow- 
ing lines.  The  deformity  is  reduced  immediately  and  the  forearm 
loosely  bandaged  on  a  single  splint.  The  patient  is  then  put 
to  bed,  the  parts  kept  perfectly  quiet  and  the  ice  cap  applied 
at  intervals  to  the  region  of  fracture.  Sedatives  or  opiates  may 
be  necessary  if  the  pain  is  severe.  The  arm  should  be  examined 
every  few  hours  to  see  that  the  swelling  is  not  great  enough  to 
cause  constriction  of  the  forearm  within  the  bandages.  During 
this  time  an  X-ray  should  be  taken  to  determine  the  exact  nature 
of  the  fracture.  When  the  swelling  is  well  subsided  the  arm  may 
be   immobilized  with  splints  as  previously  described. 

Operative  Treatment. — The  open  method  is  indicated  in  recent 
cases  when  proper  reduction  cannot  be  had  by  manipulation  and 
in  compound  cases.  Simple  angular  deformity  can,  as  a  rule,  be 
corrected  by  manipulation  unless  some  of  the  soft  tissues  become 
interposed  between  the  fractured  surfaces.  Overriding  deformity 
of  one  or  both  bones  and  multiple  fracture  of  one  of  the  shafts 
are  the  conditions  most  often  rendering  operation  necessary. 
Fracture  of  the  raelius  is  best  exposed  through  a  longitudinal  inci- 
sion on  the  outer  aspect  of  the  forearm.  The  skin,  fascia"  and 
aponeuroses  are  divided  with  the  scalpel  and  the  underlying  mus- 
cles separated  by  blunt  dissection.  When  the  fracture  is  low  in 
the  radial  shaft  care  should  be  taken  not  to  divide  the  tendons  of 


226  FRACTURES    AXO    DIST.orATTOXS 

the  extensor  muscles  of  the  thumb  which  i)ass  obliquely  across 
the  outer  aspect  of  the  lower  end  of  the  radius.  The  position 
of  the  radial  pulse  should  be  noted  before  making  the  incision  to 
avoid  injury  to  the  artery  when  anomalously  placed.  With  the 
fragments  exposed  reduction  is  accomplished  by  direct  manii)ula- 
tion  and  the  serrations  fitted  accurately  together.  IniciiiMl  fixa- 
tion will  usually  be  unnecessary  if  the  ulna  has  not  been  injured. 
Not  infrequently  one  or  both  fragments  show  a  disposition  to  slip 
out  of  place  toward  the  ulna.  "When  this  occurs  it  may.  be  possible 
to  prevent  recurrence  of  deformity  by  a  single  loop  of  wire  holding 
the  fractured  surfaces  opposed  or  it  may  be  necessary  to  employ  a 
small,  light  Lane  i)late. 

In  operating  on  the  ulna)-  shaft  it  is  best  to  expose  fhe  frag- 
ments through  a  longitudinal  incision  a  little  internal  to  the  pos- 
terior subcutaneous  border.  The  fragments  are  reduced  in  a  man- 
ner similar  to  that  just  described  in  operating  on  the  radial  shaft, 
and  internal  fixation  used  or  not,  according  to  the  needs  of  the 
case  in  hand. 

When  hoth  hones  are  fractured  the  shafts  should  be  exposed 
through  two  incisions  as  already  described  in  operating  on  isolated 
fractures  of  either  shaft.  It  is  a  mistake  to  attempt  to  expose 
both  shafts  through  one  incision  since  the  injury  to  the  soft  tissues 
will  be  more  extensive.  Theoretically  this  Avould  not  seem  to  be 
the  case,  but  practically  it  will  be  found  to  be  true.  Internal 
fixation  is  more  frequently  necessary  when  both  bones  are  frac- 
tured than  in  instances  of  isolated  fracture  of  either  the  radial  or 
ulnar  shaft. 

In  severe  compound  cases  w^here  there  has  been  considerable  loss 
of  bony  tissue  in  one  of  the  shafts  it  has  often  been  found  neces- 
sary to  resect  a  portion  of  the  opposite  shaft  to  make  the  two  bones 
of  equal  length.  This  procedure  has  in  man.y  instances  resulted  in 
useful  arms  which  would  otherwise  have  been  severely  crippled, 
but  before  it  is  employed  in  any  given  case  we  should  consider 
the  possibility  of  an  autoplastic  transplantation  of  a  portion  of  the 
shaft  of  the  patient's  fibula  or  a  section  of  the  tibial  crest  into  the 
shaft  of  the  deficient  bone.  (See  "Bone  Transplantation"  on  page 
771.) 

Severe  compound  cases  should  be  treated  according  to  the  prin- 
ciples laid  down  under  the  heading  of  "The  Treatment  of  Com- 
pound Fractures  and  Luxations"  on  page  789.     Severed  arteries 


FRACTIIRRS   OF    RADIAT.    AND    UT.NAK    SHAFTS 


227 


Fig.     3i;!. — Anl('r()-ii(is(('ri(H-     view     iil'     rriicliirc     of 
ovpvriding;  dt't'drniity.      Ndn-opcr.-il  i\c   i-i'(luc(  icni    irii]iiis.silili 


r    ilif    forearm    with 


Fig.   314. — Lateral  view  of   same   case. 


Fig.   315. — Antero-i)osterior    view    of    same    case    after    operation    and    internal    fixation. 


Fig.   310. — Lateral   view   after    operation. 


22S  FKAcrruKs  axd  disloca-i'iuxs 

should  1)0  li.uiilfil  ;iinl  iM'iVfs  siitiii'cd  ill  cases  wluTc  tlicy  arc  t'oniul 
divided. 

After-Treatment.  Duriiiu'  the  lirst  few  da\s  llic  haiidatics  slumUl 
be  very  loose  and  Hie  dressings  frequently  inspected  to  see  that 
there  is  no  strangulation  of  the  parts.  The  condition  of  the  cir- 
culation F)eneath  the  nails  iiia\  he  easily  ascertained  and  conipareil 
with  the  opposite  side.  Theiv  is  no  region  in  the  hody  in  which 
strangulation  is  more  likely  to  take  place  llian  in  the  foreann  and 
the  results  may  be  disastrous.  X'olkniaiiii  "s  eont  lael  ui-e  is  a  ])0S- 
sibility  which  must  l)e  kept  constant  ly  in  mind  diiiinu'  the  aftei-- 
treatment  of  fractures  of  Hie  foreann.  (See  "  X'olkiiianii 's  Con- 
tractui'e,"  page  281.)  The  skin  oxer  the  head  of  the  ulna  often 
calls  for  special  care  to  avoid  irritation,  (ientle  massage  after  the 
subsidence  of  the  traumatic  swelling  is  of  gi'eat  value  in  keeping 
the  soft  tissues  in  good  condition  during  the  process  of  bone  heal- 
ing but  the  greatest  care  sliouhl  be  exercised  to  avoid  disturbing 
the  fragments.  Union  may  be  expected  in  children  in  three  weeks 
or  even  less,  but  the  forearm  should  be  prolected  j)y  retaining  the 
posterior  splint  for  another  ten  days.  The  forearm  should  be  sub- 
jected to  only  the  gentlest  use  for  two  or  three  weeks  following  the 
removal  of  all  splints.  Active  motion  in  all  directions  will  be 
weak  and  limited  on  removal  of  the  splints,  but  function  will 
return  rapidly  Avith  use  and  massage.  The  parts  should  be  in- 
spected at  least  daily  for  the  first  ten  days  to  properly  accommo- 
date the  dressings  to  the  varying  size  of  the  forearm;  after  ten 
days  the  dressings  should  be  removed  at  least  twice  a  week  to 
recognize  and  correct  deformity,  should  it  take  place.  If  fiat 
splints  are  used,  as  shown  in  Figs.  283  and  312,  one  splint  may  be 
removed  without  disturbing  the  other,  and  we  are  thus  enabled  to 
inspect  the  parts  wdthout  entirely  removing  the  support  from  the 
liroken  bones.  Plaster  s{)lints  and  the  plaster  cast  have  been  suc- 
cessfully used  in  the  treatment  of  fractures  of  the  forearm  but  they 
are  dangerous  appliances  except  in  the  hands  of  the  expert.  If 
plaster  of  Paris  had  never  been  emplo\'ed  in  the  treatment  of 
fractures  of  the  forearm  Yolkmaiurs  contracture  would  have  been 
much  less  common. 

If  the  fractures  are  at  or  above  the  middle  of  tln^  shafts  the 
internal  or  external  right  angle  splint  should  be  retained  through- 
out as  a  necessary  part  of  the  dressing. 

Bowing  may  result  from  using  the   forearm  too  soon   and   the 


FRACTURES   OP    RADIATj    AND    ULNAR    SIIAPTS 


229 


patient  should  be  warned  to  avoid  nridue  strain  on  tlic  boiKis  i'or 
a  period  varying  from  one  to  four  months  folk)wino'  fracture. 
When  there  is  doubt  as  to  the  satisfactory  ossification  of  the  callus 
it  is  advisable  to  base  our  after-treatment  on  X-ray  tindini>s.  In 
adults  four  to  five  weeks  will  be  necessary  before  the  callus  is 
strong  enough  to  allow  permanent  removal  of  the  splints.  Old 
persons  produce  bone  slowly  and  should  be  allowed  15  to  20  per- 


Fig.  317. — Slight  bowing  deformity  following  fracture  of  both  bones  of  the  fore- 
arm. The  deformity  here  is  due  to  overriding  of  the  radial  fragments.  Note  the  hand 
which  is  displaced "  slightly  to  the  radial  side  and  a  little  backward.  Operation  was 
advised  in  this  case  but  refused.  Function  restored  but  slight  deformity  persists.  A 
deformity  such  as  this  will  diminish  with  years  provided  the  patient  is  young.  Picture 
taken   about  four   and   a   half   weeks   following   fracture. 

cent  more  time  than  is  allowed  healthy  adults.  During  the  after- 
treatment  the  fingers  should  be  manipulated  daily,  especially  in  old 
persons,  as  otherwise  adhesions  form  about  the  tendons  and  mus- 
cles and  between  the  joint  surfaces,  which  may  prove  a  permanent 
source  of  restricted  motion. 

Prognosis. — The  prognosis  in  fractures  of  the  bones  of  the  fore- 
arm varies  greatly  according  to  the  conditions  present.  Accurate 
reduction  of  the  fragments  in  a  healthy  child  or  adult  should  be 


230 


FRACTURES   ANP    IMSI.OPATIONS 


followed  by  complete  restoration  of  function.  Deformity  may  pro- 
duce loss  of  function.  The  rotary  action  of  the  forearm  is  most 
frequently  interfered  witli,  the  most  common  causes  being  an 
outward  bowing  of  the  shaft  of  the  radius  or  the  extension  of  the 
callus  from  the  shaft  of  the  ulna  to  the  radius  when  the  fragments 
of  tliese  two  bones  are  disjilaced  toward  each  otlier.     Loss  of  the 


Fig.   318. 


Jb'ig.   319    (top). 


Fig.   320. 


Figs.  318,  319  and  320. — Three  views  of  a  case  of  Volkmann's  paralysis.  This  case 
is  an  e.xample  of  a  most  disastrous  condition  which  may  follow  too  tight  bandaging  of 
the  forearm.  In  this  case  there  had  been  no  fracture.  The  patient  sustained  a  lacerated 
wound  involving  one  of  the  large  arteries  and  an  Esmarch  tourniquet  was  applied  and 
left  in  position  for  over  twelve  hours  while  the  patient  was  being  brought  to  the  city 
for  surgical  treatment.  Myositis,  paralysis  and  contracture  followed.  Case  first  seen 
by    author   some   years   after    the    injury. 

power  of  supination  may  follow  fracture  of  the  radial  shaft  be- 
tween the  insertions  of  the  biceps  and  pronator  radii  teres  if  not 
treated  in  supination  as  previously  mentioned.  Non-union  of  frac- 
tures of  the  forearm  is  not  common  but  when  it  does  take  place  it 
is  usually  the  result  of  the  interposition  of  soft  tissues  between  the 
fractured  ends  rather  than  to  constitutional  causes  or  defective 
immobilization.  When  due  to  the  interposition  of  muscle  or  fascia 
the  prognosis  will  depend  on  whether  or  not  operative  procedures 
are  instituted  and  the  fractured  surfaces  brought  into  contact.  A 
careful  study  of  X-ray  plates  taken  in  two  planes  will  as  a  rule 
disclose  the  presence  of  interposed  tissues  early  in  the  course  of 
the  case,  and  if  the  proper  surgical  measures  are  then  instituted 


FRACTURES   OP    RADIAL   AND    ULNAR    SHAFTS  231 

there  will  be  no  occasion  for  noii-niiion.  Slight  bovvin<^'  in  a  child 
will  usnally  correct  itself  as  years  go  by  l)ut  this  fortunate  condi- 
tion is  no  reason  for  the  surgeon  not  insisting  on  th(;  most  perfect 
possible  reduction  following  tlie  accident. 

Volkmann's  paralysis  (or  contracture)  is  a  paralysis  of  the  fore- 
arm with  wasting  of  the  muscles  and  contracture.  The  first  cause 
is  said  to  be  an  ischemia  which  is  followed  by  myositis  and  ultimate 
destruction  of  muscular  tissue  which  is  replaced  by  scar  tissue. 
The  function  of  the  nerves  may  be  subsequently  destroyed  by  con- 
traction of  the  scar  tissue  as  well  as  by  disuse.  The  points  at  which 
nerve  constriction  most  commonly  takes  place  are  where  the  median 
passes  between  the  heads  of  the  pronator  radii  teres,  and  the  ulnar 
nerve  between  the  heads  of  the  flexor  carpi  ulnaris.  Volkmann's 
paralysis  usually  follows  fractures  of  the  upper  extremity  in  chil- 
dren (especially  fractures  of  the  forearm)  and  is  the  result  of  too 
tight  bandaging  or  interference  with  the  circulation  from  some 
other  cause. 

Pain  may  be  present  with  the  onset  of  the  condition,  but  is  no 
guide  whatever  to  the  damage  the  forearm  may  be  undergoing 
from  too  tight  bandaging.  The  fingers  are  swollen  and  show  passive 
congestion,  the  hand  and  forearm  are  numb  and  uncomfortable  but 
seldom  painful.  Later  on  contracture  develops  in  which  the  wrist 
is  flexed,  the  proximal  row  of  phalanges  hyperextended  and  the 
middle  and  distal  rows  flexed.  (See  Figs.  318,  319  and  320.)  If 
the  condition  is  allowed  to  go  uncorrected,  contraction  of  the  scar 
tissue  replacing  the  muscles  is  likely  to  destroy  the  nerves,  and  all 
electric  reaction  will  be  lost. 

If  the  case  is  seen  early  (within  a  few  days  or  a  week),  massage 
and  forcible  passive  motion  with  removal  of  all  dressing,  regardless 
of  the  presence  of  fracture,  should  be  followed  by  complete  restora- 
tion of  function.  If  the  ease  is  first  seen  after  the  establishment  of 
the  contracture,  surgical  measures  will  be  necessary,  and  even  then 
the  restoration  of  function  is  usually  only  partial.  The  condition  of 
the  nerves  should  be  determined  and  then  the  procedure  most  likely 
to  give  good  results  chosen,  ]\Iyotomy  may  be  performed,  the 
nerves  may  be  dissected  out,  the  flexor  tendons  may  be  lengthened 
or  the  radius  and  ulna  may  be  shortened.  Passive  motion  and 
massage  are  most  important  following  operation. 


CHAPTER  XYII. 

FRACTURES  OF  THE  LOWER  END  OF  THE  ULNA. 

Surgical  Anatomy. — Isolated  fracture  of  the  lower  end  of  the 
ulna  is  not  a  common  injury  and  its  importance  is  much  less  than 
fractures  of  the  lower  end  of  the  radius.  Uncomplicated  fracture 
in  this  region  is  almost  invariably  due  to  direct  violence.  The 
lower  end  of  the  ulna  is  only  slightly  larger  than  the  shaft  above 
it  and  transverse  stress  is  about  the  only  tyi)e  of  strain  to  which 
it  is  subjected.  It  forms  the  center  about  which  the  lower  end 
of  the  radius  revolves  during  supination  and  pronation.  Longi- 
tudinal stress,  such  as  sustained  in  falls  on  the  hand,  is  transmitted 
through  the  radius  directly  to  the  humerus,  and  from  the  radius 
to  the  ulnar  shaft  b,y  means  of  the  interosseous  membrane.  The 
lower  end  of  the  ulna  remains  free  from  this  type  of  strain,  be- 
coming involved  only  when  the  radius  breaks ;  the  pull  of  the 
triangular  fibro-cartilage  may  then  fracture  the  ulnar  styloid. 
The  lower  end  of  the  ulna  does  not  enter  into  the  formation  of  the 
wrist  joint  but  articulates  with  the  upper  surface  of  the  triangular 
fibro-cartilage  and  the  sigmoid  cavity  of  the  radius.  In  pronation, 
the  head  of  the  ulna  presents  at  the  back  of  the  wrist,  while  in 
supination  the  styloid  process  alone  is  palpable.  Fractures  of  the 
lower  end  of  the  ulna  are  often  situated  just  above  the  head  and 
are  usually  transverse.,  though  thej^  may  be  oblique  or  longitudinal 
and  involve  the  head  or  styloid  process.  The  most  common  break 
of  this  portion  of  the  ulna  is  seen  accompanying  Colles'  fracture 
and  consists  in  an  avulsion  of  the  styloid.     (See  Figs.  326  to  331.) 

Epiphyseal  separations  may  occur  but  are  quite  rare.  The  lower 
epiphysis  (including  the  head  and  styloid)  is  ossified  from  a  single 
center  which  is  first  seen  about  the  fourth  year.  It  joins  the  shaft 
at  about  the  twentieth  year.  An  anomalous  ossicle,  the  triangulare, 
is  sometimes  seen  just  below  the  tip  of  the  ulnar  styloid  and  may 
be  mistaken  for  fracture  of  this  process  in  interpreting  X-ray 
plates  of  this  region.     (See  Figs.  405  and  406.) 

On  the  posterior  aspect  of  the  lower  end  of  the  bone  is  a  shallow 

232 


FRACTURES   OF   LOWER   END   OF    ULNA 


233 


Fig.  321. — Fracture  of  both  bones  of  the  forearm  and  separation  of  the  lower  ulnar 
epiphysis.  The  separated  epiphysis  forms  a  slight  prominence  on  the  ulnar  side  of  the 
wrist  which  may  be   seen   and  felt.      Photogi-aph  taken   a  few  minutes  following   ar-cident. 


323. 


Figs.  822  and  323. — X-ray  plates  showing  antero-posterior  and  lateral  views  of  the 
case  seen  in  Fig.  321.  l  and  2,  fracture  in  ulnar  shaft;  3  and  4,  fracture  in  radial 
shaft;    5,  displaced  ulnar  epiphysis. 


234  FRACTURES   AND   DISLOCATIONS 

^i-()()vc  toi-  tlio  passaji:o  of  the  tendon  of  the  extensor  ear])i  ulnaris. 
Symptoms. — Tlie  symptoms  accompanying  isohited  fracture  of 
the  lower  end  of  the  ulna  are  often  surprisingly  mild.  There  is 
local  pain,  tenderness,  swelling  and  a  varial)le  degree  of  loss  of 
function.  Since  the  condition  usually  results  from  direct  violence 
there  will,  as  a  rule,  be  evidences  of  the  blow  on  tiic  skin  in  this 
region.  If  the  trauma  is  severe  the  condition  may  he  compound. 
Su|)ination  and  i)ronation  are  often   particuhirly   painful   and  the 


Fig.    324. — Fracture    and    beparaliou    ol'    a    portitm    of    tlie    ulnar    epipliysis    including 
the  styloid  process. 

wrist  lacks  lateral  stability  though  the  movements  of  the  wrist 
itself  are  mechanically  undisturbed.  Direct  palpation  will  elicit 
crepitvis  if  the  fragments  are  manipulated.  The  lower  end  of  the 
upper  fragment  may  be  displaced  in  any  directioii  though  it  is 
more  connnon  to  find  it  nearer  the  radius  than  normal  and  })rom- 
inent  posteriorly.     Deformity,  however,  is  usually  slight. 

Diagnosis. — Fracture  of  the  lower  end  of  the  ulna  can,  as  a  rule, 
be  recogni/ed  without  difficulty  if  the  parts  are  carefully  exam- 
ined.    There  is  no  characteristic  deformity  and  hence  inspection 


FRACTURES   OF   LOWER   END   OP    UI^NA  235 

alone  is  of  little  value.  Tlie  condition  is  most  frequently  over- 
looked when  it  occurs  accorni)anyin<^  (Jolles'  fracture.  The  broad- 
ening of  the  wrist  seen  in  Colles'  fracture  is  due  to  rupture  of  the 
triangular  fibro-cartilage  or  to  avulsion  of  the  styloid  (usually 
the  latter)  and  is  suggestive  of  fracture  of  the  lower  end  of  the 
ulna.     When  doubt  exists  the   X-ray  should  be   employed. 

Treatment. — This  fracture  is  not  a  serious  one  as  compared  to 
other  breaks  in  this  region  and  reduction  of  the  displacement  is 
usually  accomplished  without  difficulty.  If  the  tendon  of  the 
extensor  carpi  ulnaris  tends  to  displace  the  lower  fragment  the 
hand  should  be  treated  in  a  position  of  dorsal  flexion  and  ad- 
duction. A  single  anterior  splint  extending  from  the  base  of  the 
fingers  to  the  upper  part  of  the  forearm  will  usually  suffice  in 
immobilizing  the  parts.  Direct  pressure  may  be  exerted  by  pads 
of  gauze  secured  in  position  by  strips  of  adhesive  plaster.  Direct 
pressure  is  not  often  indicated,  but  when  it  is  it  will  usually  be 
found  necessary  because  of  a  tendency  on  the  part  of  the  lower  end 
of  the  upper  fragment  to  backward  deformity.  Under  these  cir- 
cumstances direct  pressure  should  be  exerted  on  the  shaft  of  the 
bone  above  the  level  of  the  fracture.  Tight  bandaging  is  as  dan- 
gerous here  as  in  the  treatment  of  fractures  of  the  shafts  of  the 
bones  of  the  forearm,  and  the  same  precautions  are  to  be  observed 
as  already  mentioned  in  the  preceding  section.  The  forearm 
should  be  carried  in  a  sling  which  supports  its  entire  length  as 
otherwise  it  may  exert  a  displacing  action  on  the  fragments. 

Operative  Treatment. — Open  treatment  is  rarely  indicated  in 
recent  cases  aside  from  compound  conditions.  When  the  fracture 
is  open  it  is  to  be  treated  according  to  the  principles  laid  down 
under  "The  Treatment  of  Compound  Fractures  and  Luxations," 
on  page  789.  If  deformity  recurs  or  persists  and  cannot  be  con- 
trolled by  ordinary  methods  the  fragments  should  be  secured  by 
internal  fixation  (see  page  754). 

After-Treatment. — The  forearm  should  be  frequently  inspected 
during  the  first  week  or  ten  days,  especially  if  the  secondary 
traumatic  reaction  is  pronounced.  Undue  constriction  of  the  fore- 
arm is  as  dangerous  here  as  in  fractures  of  the  shafts  of  the  bones 
of  the  forearm  and  may  lead  to  Volkmann's  Contracture  (see 
page  230).  Immobilization  for  three  to  four  wrecks  should  result 
in  union.  Fracture  of  the  styloid  and  displacement  of  the  lower 
end  of  the  ulna  will  be  considered  under  "Fractures  of  the  Lower 


236  FRACTURES   AND    DISLOCATIONS 

End  of  the  Radius,"  since  it  most  l're(|uriitly  oeeiirs  as  a  comi)!!- 
cation   of  Colles'   fracture. 

Prognosis. — The  outlook  in  unconiplieated  fracture  of  tlie  lower 
end  of  the  ulna  is  pood  hotli  as  to  function  and  deformity.  Fibrous 
union  is  sometimes  seen  hut  does  not  as  a  rule  materially  lessen 
function.  AVhen  the  condition  is  compound  the  ])ro,u'nosis  is  of 
course  worse,  but  it  is  rare  to  see  disability  t'ollowiim  fractures  in 
this  region. 


CHAPTER  XVIIT. 

LUXATIONS  OF  THE  LOWER  END  OF  THE  ULNA. 

Surgical  Anatomy. — The  lower  end  of  the  ulna  articulates  with 
the  superior  surface  of  the  triangular  fibro-cartilage  and  the  sig- 
moid cavity  of  the  radius.  The  lower  end  of  the  radius  describes 
an  arc  about  the  head  of  the  ulna  during  supination  and  pronation 
and  the  center  of  the  arc  thus  described  is  the  attachment  of  the 
apex  of  the  triangular  fibro-cartilage  in  the  depression  between 
the  ulnar  head  and  styloid.  This  triangular  cartilage  is  the 
only  ligament  in  the  lower  radio-ulnar  articulation  which  main- 
tains the  ends  of  the  bones  in  apposition.  The  anterior  and  pos- 
terior radio-ulnar  ligaments  extend  transversely  in  front  of,  and 
behind,  the  joint  and  limit  its  rotary  action.  The  lower  end  of 
the  ulna  does  not  enter  into  the  formation  of  the  w^rist  joint.  A 
separate  synovial  sac  exists  between  the  lower  end  of  the  ulna  and 
the  cartilage,  and  extends  upward  between  the  radius  and  ulna. 
Isolated  luxation  of  the  lower  end  of  the  ulna  is  an  extremely  rare 
accident  though  it  has  been  recorded  in  a  sufficient  number  of 
cases  to  establish  it  as  a  type.  A  more  or  less  complete  dislocation 
of  this  joint  is  not  an  uncommon  complication  of  Colles'  fracture 
and  is  the  result  of  rupture  of  the  triangular  fibro-cartilage  or  an 
avulsion  of  its  ulnar  attachment.  This  condition  has  been  fully 
considered  under  "Fractures  of  the  Lower  End  of  the  Radius," 
(page  242),  and  appropriately  so,  since  it  is  secondary  to  and  a 
complication  of  Colles'  fracture. 

It  is  probable  that  no  one  observer  has  seen  more  than  one  un- 
complicated luxation  of  the  lower  end  of  the  ulna  and  hence  the 
details  of  the  condition  are  not  as  Avell  known  as  they  might  be. 
The  author  has  seen  but  one  case.  Experiments  which  the  author 
has  conducted  on  the  cadaver  showed  that  rupture  of  the  tri- 
angular fibro-cartilage  or  avulsion  of  one  of  its  attachments  was 
necessary  for  inward  luxation.  Rupture  of  the  posterior  radio- 
ulnar ligament  was  regularly  found  in  posterior  dislocations  and 
tearing  of  the  anterior  ligament  was  noted  in  forward  luxations. 

237 


238  FRACTURES    AND    DISLOCATIONS 

Extreme  pi-oiiatioii  produced  tension  on  the  posterior  fibres  of  the 
triangular  tibro-eartilage  while  extreme  supination  rendered  the 
anterior  fibres  taut.  Eeduction  was  accompanied  by  a  distinct 
snap  in  all  cases  in  wliidi  tlie  triangular  fil)ro-c*artilage  remained 
unruptured. 

Clinically,  three  types  of  luxation  of  the  lower  end  of  the  ulna 
have  been  observed : — namely,  backward,  forward  and  inward.  In 
the  haclxward  type  the  head  occupies  a  position  just  behind  the 
postero-internal  angle  of  the  quadrilateral  lower  end  of  the  radius. 
The  posterior  ligament  is  torn  while  the  triangular  fibro-cartilage 
remains  intact.  This  type  of  luxation  is  more  commonly  seen  as 
a  complication  of  ''reversed  Colles'  fracture"  and  is  due  to  hyper- 
pronation  of  the  wrist.  I)i  fix  forward  type  of  luxation  the 
lower  end  of  the  ulna  is  displaced  forward  and  slightly  outward, 
and  in  isolated  cases  is  probably  caused  by  hypersupination.  As 
a  complication  of  fracture  of  the  lower  end  of  the  radius  it  is  not 
uncommon.  The  inward,  type  occurs  only  with  ru])ture  of  the 
interarticular  cartilage  and  as  an  isolated  injury  is  so  rare  as  to  be 
questionable.  As  a  complication  of  Colles'  fracture  it  is  not  at 
all  uncommon. 

Symptoms. — The  symptoms  accompanying  luxations  of  the  lower 
end  of  the  ulna  depend  on  the  length  of  time  the  displacement 
has  persisted  and  the  position  occupied  by  the  head  of  the  ulna. 
In  recent  cases  tliere  is  pain,  swelling,  tenderness,  loss  of  func- 


Fig.   325. — 'Posterior  luxation   of  lower   end   of   ulna.      X'ote  the   abnormal  prominence 
at  the  back  of  the  wrist  on   tlie  ulnar  side. 

tion,  etc.  The  deformity  and  disturbance  in  function  depend  on 
the  type  of  luxation.  //;  iJie  bad- ward  va rift y  the  wrist  is  in 
extreme  pronation,  narrower  than  noi-mal  and  the  prominence  of 
the  displaced  head  is  apparent.     The  hand   is  slightly  adducted. 


LUXATIONS   OF    LOWER   END   OP    ULNA  239 

supination  is  impossible  as  loni;-  as  Ihc  luxation  exists,  and  there 
is  loss  of  power  in  the  finders  and  wrist.  In  the  forward  type  the 
forearm  is  fixed  in  supination  and  the  ulnar  head  may  he  palpated 
on  the  palmar  aspect  of  the  wrist  above  the  pisiform.  The  wrist 
appears  narrower  than  normal  and  the  absence  of  the  ulnar  head 
from  its  normal  position  is  apparent.  The  inward  type  of  luxa- 
tion shows  a  broadening  of  the  wrist  with  loss  of  power  in  the 
rotary  action  of  the  forearm.  The  symptoms  of  inward  luxation 
are  a  part  of  the  clinical  picture  in  many  cases  of  Colles'  fracture, 
and  as  such  have  been  described  under  "Fractures  of  the  Lower 
End  of  the  Radius."  As  an  isolated  injury  this  dislocation  is  a 
surgical  curiosity. 

Chronic  and  recurrent  luxations  of  the  lower  end  of  the  ulna 
are  occasionally  seen  and  the  symptoms  differ  considerably  from 
the  acute  condition.  A  chronic  backward  subluxation  is  sometimes 
seen  in  children  as  a  result  of  heavy  Avork  while  the  bones  are 
still  in  a  soft  and  developmental  stage  and  is  known  as  ]\Iadelung's 
deformity.  This  backward  displacement  develops  gradually  as  the 
radial  deformity  increases,  and  with  removal  of  longitudinal  pres- 
sure the  ulna  grows  proportionately  faster  than  the  radius. 

Recurrent  luxation  of  the  lower  end  of  the  ulna  is  an  extremely 
rare  condition  sometimes  seen  following  trauma  in  this  region. 
The  displacement  is  usually  not  pronounced,  but  the  lower  end  of 
the  ulna  is  likely  to  slip  out  of  position  with  extreme  supination 
or  pronation.  Reduction  is  easy  and  usually  accomplished  by  the 
patient.  The  annoyance  and  interference  with  function  may  be 
marked  and  is  sometimes  accompanied  by  ulnar  neuritis. 

Diagnosis. — There  should  be  little  difficulty  in  recognizing  dislo- 
cations of  the  lower  end  of  the  ulna.  The  displaced  head  of  the 
bone  may  be  palpated  and  is  characteristic  of  the  luxation  accord- 
ing to  the  direction  of  displacement.  In  the  forward  type  the 
wrist  is  narrower  than  normal  and  fixed  in  supination.  In  the 
backward  type  it  is  narrower  than  normal  and  fixed  in  pronation. 
The  broadening  of  the  wrist  is  typical  of  inward  luxations  which 
are  almost  never  seen  except  as  a  complication  of  Colles'  fracture. 
Luxations  of  this  joint  are  most  frequently  overlooked  when  they 
exist  as  complications  of  Colles'  fracture,  and  this  is  because  one 
is  apt  to  feel  that  the  diagnosis  is  complete  as  soon  as  the  fracture 
has  been  recognized. 

Treatment. — The  method  of  reduction  will  depend  on  the  type 


240  FRACTURES    AND   DISLOCATIONS 

of  luxation  present.  In  backward  dislocations  pressure  should  be 
exerted  with  the  thumbs  to  force  the  lower  ends  of  the  bones  apart 
while  the'  wrist  is  being  carried  into  supination.  The  object  is 
to  force  the  head  of  the  ulna  around  the  postero-internal  angle 
of  the  lower  end  of  the  radius  and  then  carry  the  forear-ni  into 
supination.  Reduction  is  accompanied  by  a  distinct  snap  as  the 
ulnar  head  clears  the  prominence  and  settles  back  into  the  sig- 
moid cavity  of  the  radius.  Reduction  of  the  anterior  luxation  is 
accomplished  by  forcing  the  ulnar  head  backward  and  inward 
around  the  antero-internal  angle  of  the  lower  end  of  the  radius 
and  then  carrying  the  forearm  into  pronation.  Reduction  of  this 
luxation  is  also  accompanied  by  a  distinct  snap  if  tlie  triangular 
tibro-cartilage  is  not  ruptured.  Uncomplicated  inward  luxation  of 
the  head  of  the  ulna  would  probably  offer  little  or  no  resistance  to 
reduction  and  the  tendency  to  recurrence  would  be  slight.  The 
condition,  however,  is  practically  unknown  as  an  isolated  injury. 
When  it  occurs  as  a  complication  of  CoUes'  fracture  it  is  difficult 
to  keep  the  luxated  ulnar  head  in  position  because  the  radius  has 
been  shortened  by  fracture.  In  recent  cases  there  is  little  tend- 
ency to  recurrence  of  deformity  if  the  luxation  is  either  forward 
or  backward.  In  old  cases  it  may  be  impossible  to  effect  reduction 
by  manipulation,  especially  if  the  ulna  has  outgrown  the  radius  in 
length. 

Operative  Treatment. — Operative  treatment  is  practically  never 
indicated  in  recent  cases  unless  the  condition  is  a  complication 
of  Colles'  fracture  and  the  break  calls  for  open  treatment  to 
effect  or  maintain  reduction.  In  old  unreduced  luxations  and 
when  the  condition  is  congenital  it  may  be  necessary  to  operate  to 
restore  the  bones  to  their  normal  relations.  In  old  cases  it  may  be 
necessary  to  resect  the  ulnar  head  when  the  ulna  has  outgrown 
the  radius.  With  the  end  of  the  bone  removed  reduction  may  be 
accomplished  and  recurrence  of  deformity  prevented  by  suturing 
the  soft  tissues.  In  recurrent  cases  it  may  be  possible  to  shorten 
the  lower  radio-ulnar  ligaments  or  their  tension  may  be  increased 
by  dividing  the  radius  about  two  inches  from  the  lower  end  and 
tipping  the  lower  fragment  so  that  the  styloid  will  occupy  a  lower 
level. 

After-Treatment. — In  recent  forward  or  backward  luxations  the 
deformity  does  not  tend  to  recur  and  hence  no  special  retentive 
apparatus  will  be  required  aside  from  avoiding  extreme  supination 


LUXATIONS   OP    LOWER   END    OF    ULNA  241 

or  pronation  according  to  the  type  of  luxation.  Should  a  tend- 
ency to  recurrence  be  present  the  forearm  should  be  immobilized 
in  a  position  of  rotation  opposite  to  that  in  which  the  luxation 
occurred.  A  backward  dislocation  should  be  fixed  in  supination 
while  an  anterior  luxation  should  be  immobilized  in  pronation. 
Two  to  three  weeks  should  be  allowed  for  the  ligaments  to  henl. 
Following  operation  the  forearm  should  be  immobilized  for  two  or 
three  weeks,  or  even  longer  in  exceptional  cases.  If  the  condition 
is  compound  it  should  be  treated  according  to  the  principles  Inid 
down  in  "The  Treatment  of  Compound  Fractures  and  Luxations," 
on  page  789. 

Prognosis. — The  outlook  in  uncomplicated  luxations  of  the  lower 
end  of  the  ulna  is  excellent  if  reduction  is  accomplished  early. 
Old  unreduced  cases  of  forward  or  backward  luxation  usually  show 
considerable  disturbance  in  function  especially  in  the  rotary  action 
of  the  forearm.  In  congenital  luxations  the  loss  of  function  is 
often  surprisingly  slight,  consisting  for  the  most  part  in  loss  of 
complete  supination,  slight  weakness  of  the  wrist  and  of  early 
tiring  when  heavy  work  is  performed.  The  same  type  of  symptoms 
prevail  in  the  backward  subluxation  seen  in  children  as  a  result 
of  heavy  work  during  the  years  when  the  bones  are  soft.  The 
operations  recorded  have  been  few  but  the  results  are  encouraging. 


CHAPTER  XIX. 

FRACTrRES  OF  THE  LOWER  END  OF  THE  RADII'S. 

Surgical  Anatomy. — The  region  of  the  wrist  is  compact  and 
contains  numerous  tendons,  nerves  and  vessels  in  close  relation  with 
the  radius,  ulna  and  carpus.  The  normal  relations  of  these  struc- 
tures and  the  surface  landmarks  should  be  known  before  one  is 
qualified  to  recognize  and  fully  appreciate  the  deformities  accom- 
panying fractures  of  the  lower  end  of  the  radius.  Variations 
within  normal  limits  are  common  in  the  lower  ends  of  the  radius 
and  ulna,  and  the  carpus  is  frequently  the  seat  of  pronounced 
anomalies.  It  is  necessary,  therefore,  that  the  opposite  wrist  be 
examined  carefully  before  determining  the  conditions  i)resent  in 
the  injured  member.  The  styloid  process  of  the  radius  normally 
occupies  a  lower  level  than  the  ulnar  styloid.  Nearly  all  fractures 
of  the  lower  end  of  the  radius  are  accompanied  by  an  elevation  of 
the  radial  styloid ;  this  condition  is  determined  by  comparing  the 
relative  levels  of  the  two  styloid  processes  as  shown  in  Fig.  376. 
The  uninjured  M-rist  is  used  as  the  standard  of  comparison  in  as- 
certaining the  distance  the  radial  styloid  has  been  raised.  On  the 
anterior  surface  of  the  wrist  will  be  noted  two  eminences.  To  the 
radial  side  is  the  thenar  eminence;  the  upper  margin  of  which  is 
at  a  slightly  low^er  level  than  the  corresi)onding  margin  of  the 
hypothenar  eminence  which  is  situated  at  the  ulnar  side  of  the 
wrist.  AVhen  the  outer  side  of  the  forearm  is  shortened  by  frac- 
ture of  the  radius  the  thenar  eminence  is  raised  according  to  the 
extent  of  the  deformity.  The  outer  aspect  of  the  lower  end  of 
the  radius  is  the  only  portion  of  the  bone  which  is  strictly  sub- 
cutaneous, yet  the  lower  half  of  the  radius  may  be  palpated  with- 
out difficulty  since  there  is  little  else  than  tendons  interposed 
betvveen  the  skin  and  the  bone. 

On  the  posterior  surface  of  the  lower  expanded  quadrilatei'al 
extremity  of  the  radius  are  a  number  of  vertical  grooves  foi-  the 
acconunodation  of  the  extensor  tendons  passing  from  the  fore- 
arm to  the  hand.     At  about  the  middle  of  this  surface  will  be 

242 


FRACTURES    OF    LOWER   END    OF    RADIUS 


248 


noted  a  prominent  rid^e  wliicli  foi^nis  tin;  outer  niarjiiin  of  tlie 
groove  for  the  passage  of  the  extensor  longus  pollieis.  The  tejulons 
of  the  extensor  ossis  metaciirpi  |)olli('is  (ind  extensor  brevis  pollieis 
pass  to  the  outer  side  of  the  radius,  o})liquely  aeross  the  base  of 


Fia:.    329. 


Fig.    330. 


Fig.    331. 


Fig.   326. — Impacted  fracture   of   lower   end   of   rwdius.      Fracture   of   ulnar   st.vloid. 

Fig.  327. — Pronounced  imisactiou  of  lower  end  of  radius.  Fracture  of  ulnar  st.vloid 
at  its  base. 

Fig.  328. — Fracture  of  ulnar  side  of  lower  end  of  radius  and  fracture  of  ulnar 
styloid. 

Fig.   329. — ^Vertical  fracture  of  lower  end  of  radius   and  fracture  of  ulnar  st.vloid. 

Fig.   330. — Comminution  of  lower  end  of  radius  and  fracture  of  ulnar  styloid. 

Fig.  331. — Extensive  splitting  and  comminution  of  lower  end  of  radius  and  frac- 
ture of  ulnar  styloid. 


the  styloid  process.  The  flexor  tendons,  radial  artery,  and  median 
nerve  pass  in  front  of  the  lower  end  of  the  bone.  The  radial 
nerve  as  it  courses  down  the  outer  side  of  the  forearm  and  under 
the  tendon  of  the  supinator  longus  is  sometimes  injured  and  may 


244 


FKACTITRES    AND    DISLOCATIONS 


give   rise   to  considerable   pain   diiriiig   the   after-treatment.     Tlie 
inner  aspeet  of  tlie  lower  end  of  the  radius  jiresents  the  ''sigmoid 


Fig.   a32. 


Fig.    3iJ3. 


Figs.   332,    333    and    334. — Three  good  examples   of   Reversed   Colles'   fracture.     The 
'gardener's   spade"    defariuity   is   present   instead   of   the   "silver-fork"    deformity. 


Fig.    ;!3fj. 


Figs.    335    and   336. — Antero-posterior    and   lateral   views   of   a  fracture   of    the   lower 
end   of   the  radius  produced  by   an   "autokick." 


cavity  of  the  radius"  for  articulation  with  the  head  of  the  ulna; 
just  beneath  the  lower  margin  of  this  surface  is  attached  the  base 
of  tlie  triangular  fibro-cartilage,  whicli  binds  the  radius  and  ulna 


FRACTURES    OP    I/)WER   END    OF    KADTITS 


245 


together.  With  the  forearm  seinipronated  the  ulnar  styloid  may 
be  palpated  as  a  prominence  of  bone  which  is  continuous  with  the 
posterior  subcutaneous  border  of  the  ulna.  The  tip  of  the  process 
is  on  a  level  with  the  articulation  of  the  wrist.  When  the  forearm 
is  carried  into  complete  pronation  the  ulnar  head,  instead  of  the 
styloid  process,  presents  beneath  the  skin.  The  inferior  surface 
of  the  lower  end  of  the  radius  articulates  with  the  upper  row  of 
carpal  bones  and  looks  downward  and  slightly  forward. 

The  internal  structure  of  the  lower  end  of  tlie  radius  shoidfi  be 
studied   to   fully   appreciate   the   mechanism   of   fractures   of   this 


Figs.  337,  338  and  339.- — Three  views  of  a  transverse  Colles'  fracture  with  impaction 
of  the  proximal  fragment  into  tlie   cancellous  tissue   of  tlie   distal  fragment. 


region.  A  short  distance  above  the  lower  end  of  the  bone  the  sur- 
face layer  of  compact  tissue  changes  rapidly  into  the  heavy  tube 
of  compact  bone  which  forms  the  shaft  of  the  radius,  and  it  is 
here  that  fracture  most  often  occurs.  It  is  not  uncommon  to  find 
the  end  of  the  upper  fragment  driven  into  the  lower  fragment, 
which  means  a  more  or  less  extensive  crushing  and  comminution  of 
the  cancellous  tissue  in  the  lower  end  of  the  radius,  and  accounts  to 
some  extent  for  the  tendency  to  recurrence  of  deformity  following- 
reduction.  Thus,  when  the  lower  fragment  is  pulled  back  into 
position  following  impaction,  there  is  a  Avedge-shaped  space  in  the 


246 


KKACTl'RES    AND    DISLOCATIONS 


lower  fragment  eorrcspoiulino'  to  the  crushed  cancellous  tissue,  and 
unless  the  layer  of  compact  bone  on  the  posterior  aspect  of  the 
lower  fragment  is  firmly  engaged  the  deformity  will  return  when 
the  iiarts  are  released.  A  consideration  of  the  internal  structure 
of  the  lower  end  of  the  radius  as  sliown  in  Figs.  268  and  384 
will  explain  this  tendency  to  recurrence  of  deformity,  and  the 
necessity  for  overcorrecting  the  displacement  so  that  the  dorsal 
layer  of  compact  tissue  may  properly  engage  the  upper  fragment. 


Fig.    340. — Fracture   of    lower    end    (if    radius    i)1-(i<1uiih1   liy    '"autii  Uiclc.' 


Fractures  in  this  region  of  tiic  skeleton  show  cousiderable  varia- 
tion, but  the  overwhelming  majority  corresi)onds,  more  or  less 
closely  to  the  type  described  by  CoUes.  Ilis  original  description 
in  1814  was  of  a  fracture  one  and  a  half  inches  above  the  articular 
surface,  but  subsequent  exp"erience  has  shown  that  the  usual  break 
is  within  three-fourths  of  an  inch  of  the  lower  end  of  the  bone. 
At  the  present  time,  therefore,  Colles'  name  is  used  to  indicate 
a  condition  slightly  different  from  the  one  originally  described  by 


FRACTdRES    OF    LOWER   END    OF    RADIUS 


247 


him.     The  typical  Colles'  fracture  is  transverse  or  oblique,  does 
not  enter  the  articular  surface  and  is  accoini)anied  by  a  backward 


Fig.   341.  Fig.   342. 

Figs.    341    and    342. — Lateral    and    anteroposterior    views    of    Colles'    fracture    with 
very  slight  deformity.     Note  fracture  of  ulnar  styloid. 


Fig.    343. — Colles'   fracture  with   comminution   of  the  distal  fragment. 

displacement  of  the  lower  fragment.  Tliis  backward  displacement 
of  the  distal  fragment  produces  the  typical  "silver-fork"  deformity 
which  is  so  characteristic  of  Colles'  fracture  (see  Figs.  354  to  367). 


248 


FRACTURES   AND   DISLOCATIONS 


Fig.   345. 


Figs.  344  and  345. — Antero-posterior  and  lateral  views  of  transverse  CoUes'  fracture 
with  impaction  of  upper  fragment  into  lower,  after  attempt  at  reduction.  Same  case  as 
shown   in   Fig.    355. 


Figs.  3i0  and  347. — Anteroposterior  and  lateral  views  of  oblique  Colles'  fracture 
after  reduction.  Same  case  as  shown  in  Figs.  366  and  367  before  reduction.  Note 
obliquity  of  plane  of  fracture  and  absence  of  crushing  of  cancellous  tissue  by  impaction. 


FRACTURKS    OF    r/)WKR    END    OK    RADIUS 


249 


The  nature  of  the  deformity  varies  somewhat  with  the  line  of  frac- 
ture (see  "Symptoms,"  page  252). 

The  usual  Colles'  fracture  is  the  result  of  a  fall  on   tlie  out- 
stretched hand.     If  the  fall  is  sustained  on  the  palm  of  tlie  liatid, 


Fig.   348. 


Figs.  348  and  349. — Antero-posterior  and  lateral  views  of  separation  of  lower  radial 
epiphysis  complicated  by  fracture  of  the  end  of  the  diaphysis.  Same  case  as  shown  in 
Figs.   368,   369   and  370. 

as  is  usual,  the  distal  fragment  is  displaced  backward  and  the 
typical  Colles'  fracture  is  the  result.  If  impaction  is  present 
it  is  the  cancellous  tissue  near  the  posterior  surface  of  the  lower 
fragment  which  suffers  most.     In  rare  instances  the  distal  frag- 


250 


FRACTURES   AND   DISLOCATIONS 


Fig.    35tl. 


Fig.    351. 


Figs.  350  and  351. — .Viitero-pusterior  and  lateral  views  of  epiphyseal  separation  of 
lower  end  of  radius  complicated  by  fracture  of  the  lower  end  of  the  diaphysis.  Deform- 
ity corresponds  to  "reversed   Colles'." 


Fig.   353. 


Figs.  352  and  353. — Antero-posterior  and  lateral  views  of  separation  of  the  lower 
radial  epiphysis  after  rediittion.  Note  the  cDtnplicating  fractures  of  botli  epiphysis  and 
diaphysis. 


FRACTURES    OP    LOWER   END   OF    RADIUS  251 

ment  may  be  displaced  ventrally  and  the  coiidilioti  is  tlien  spokf-n 
of  as  a  "reversed  Colles'  fraeture."  Tliis  type  of  deformity  is 
usually  produced  when  the  causative  trauma  is  received  on  the 
dorsal  aspect  of  the  hand  with  the  wrist  in  flexion.  Examples  of 
reversed  Colles'  fracture  are  shown  in  Figs.  332  to  334. 

An  oblique  fracture  passing  from  the  posterior  surface  of  the 
lower  end  of  the  radius  into  the  articular  surface,  with  dorsal  dis- 
placement of  the  fragment,  is  known  as  Barton's  fracture.  When 
the  break  enters  the  articular  surface  from  the  anterior  aspect  of 
the  lower  end  of  the  radius,  with  ventral  displacement  of  the  frag- 
ment, the  condition  is  spoken  of  as  a  ' '  reversed  Barton 's  fracture. ' ' 
This  terminology  is  rather  unfortunate  since  these  two  conditions 
are  in  reality  luxations  of  the  wrist  complicated  by  fracture  of 
the  lower  end  of  the  radius.  Thus  Barton's  fracture  is  a  backward 
luxation  with  fracture  of  the  posterior  lip  of  the  radius,  while 
reversed  Barton's  fracture  is  an  anterior  luxation  with  fracture  of 
the  anterior  lip  of  the  radius.  The  mechanism  of  Barton's  frac- 
ture and  reversed  Barton's  fracture  is  similar  to  that  obtaining  in 
Colles'  fracture  and  its  reversed  form. 

Atypical  fractures  of  the  lower  end  of  the  radius  show  con- 
siderable variation :  the  styloid  process  may  be  broken  off,  a  ver- 
tical fracture  may  pass  from  the  shaft  into  the  articular  surface, 
oblique  fractures  may  pass  from  either  the  inner  or  outer  aspect 
of  the  bone  into  the  articular  surface,  the  distal  fragment  of  a 
Colles'  fracture  may  be  broken  into  two  or  more  pieces  or  may  be 
extensively  comminuted,  and  the  same  condition  sometimes  exists 
in  a  separated  epiphysis,  and  finally  the  lower  end  of  the  bone  may 
be  so  extensively  comminuted  that  it  does  not  resemble  any  of  the 
above  described  fractures.  In  some  rare  instances  the  upper 
row  of  carpal  bones  have  been  driven  upward  through  the  articular 
surface  of  the  radius  so  that  they  rested  partially  within  the  can- 
cellous tissue  of  the  lower  end  of  the  bone.  In  many  of  these 
atypical  fractures  the  degree  and  nature  of  the  deformity  depend 
largely  on  the  severity  and  direction  of  the  causative  trauma. 

The  lower  epiphysis  of  the  radius  is  ossified  by  a  single  center 
which  makes  its  appearance  about  the  end  of  the  second  year.  The 
epiphyseal  cartilage  is  obliterated  during  the  twentieth  year.  The 
causes  of  epiphyseal  separations  are  similar  to  those  producing 
Colles'  fracture,  and  the  deformity  usually  consists  in  a  backward 
displacement  of  the  lower  fragment.     It  is  not  uncommon  to  find 


252  FRACTURES   AND    DISLOCATIONS 

epiphyseal  separations  of  the  lower  end  of  the  radins  complieated 
by  fracture;  examples  of  this  condition  are  shown  in  Figs.  3-18 
to  353. 

Symptoms. — The  patient  almost  invariably  gives  a  history  of 
ha\inu-  fallen  on  the  outstretched  hand.  The  injury  is  followed 
innnediately  by  severe  pain  and  loss  of  function,  and  the  sufferer 


tig.  354. —  lypic'iil  Colles'  fracture  a  few  minutes  following  the  accideut.  Fracture 
transverse  and  iinpaetion  present.  Compare  this  deformity  with  the  other  Colles'  frac- 
tures shown   in   thi.s  ehai-ter   ;ind   wilh  the  backward   dislocation   shown   in   Fig.   378. 


Fig.    355. — .Simple   (holies'    fracture   the  result  of   a   fall   on   tlie   liand.      Picture   taken 
a  short  time  following  the  accident.      Appearance  typical. 

presents  himself  for  treatment  and  relief.  The  attitude  is  usually 
characteristic.  He  stands  with  the  shoulders  slightly  forward  and 
the  forearms  held  horizontally  across  the  body.  The  injured  mem- 
ber is  supported  by  the  opposite  hand  and  there  is  considerable 


FRACTURES   OF    LOWER   END    OP    RADIUS 


253 


Pig.    356.      An   example   of   the  radiiil    (lis|)l;iit'ment  of  the   distal  fragment   sometimes 
seen  in   Colles'   fracture.      Note  how  the  whole   hand   is   displaced  to   the   radial  side. 


Pig.   357. 


Pigs.  357  and  358. — Transverse,  impacted  Colles'  fracture  a  few  minutes  following 
fall  on  hand.  This  is  the  type  of  deformity  illustrated  in  B.,  Fig.  384.  Compare  this 
case  with  the  deformity  accompanying  an  oblique  Colles'  fracture  as  shown  in  Figs.  366 
and  367.  Angular  deformity  is  here  present  as  a  result  of  the  impaction,  and  the  direc- 
tion in  which  the  articular  surface  of  the  radius  looks  has  been  changed.  Note  the 
prominence  on  the  ventral  and  ulnar  side  of  the  wrist  produced  by  the  displaced  head  of 
the  ulna. 


254 


FRVCTFRES    AND    DISLOCATIONS 


anxiety  in  botli  altitude  and  uait  lest  tlic  injured  wi-ist  hr  dis- 
turbed. The  onset  of  swelling  about  the  wrist  is  prompt  and 
sometimes  pronounced,  and,  unless  the  case  is  seen  inunediately 
following  the  accident,  the  deformity  is  to  some  extent  masked. 


Fig.  :j59. —  Fhotogr;ii)h  of  a  recent  C'olles'  fi'acture  showing  the  change  in  Uip  con- 
tour of  the  wrist  resulting  from  the  disphicenient  of  the  distal  fragment.  The  articular 
surface  of  the  radius  looks  downward  and  backward  instead  of  downward  and  slightly 
forward  as  is  normal.  Note  the  curve  on  the  anterior  surface  of  the  wrist  which  is 
less  sharp  than  is  seen  in  a  normal  wrist  in  this  position. 


Fig.   361. 


Figs.    360    and    361. — Colles'    fracture   a   few   minutes   following    injury.      Prominence 
on  ventral  surface  of   forearm   is   due  to   distention  of  the  fle.xor  tendon   sheaths. 


Loss  of  function  in  the  liand  and  wrist  is,  as  a  rule,  complete,  and 
even  in  instances  in  which  it  might  be  possible  for  the  patient  to 
perform  some  acts  with  the  injured  member  the  pain  is  usually 
severe  enough  to  inhibit  all  function. 

The  usual  silver-fork  deformity  is  characteristic  of  Colles'  frac- 


FRACTURES   OP   LOWER   END    OP    RADIUS 


255 


Fig.   363. 

Figs.    362    and    363. — Radial    and    ulnar   views    of   recent    Colles'    fracture.      Line    of 
fracture   a  little  higher   than   usual   and   dorsal   displacement  pronounced. 


Fig.   364. 


Figs.  364  and  365. — Radial  and  ulnar  views  of  Colles'  fracture  in  old  woman  a 
few  minutes  following  the  accident.  Angular  deformity  and  impaction  present.  Moderate 
displacement  of  lower  fragment.  Note  prominence  of  ulnar  head  and  displacement  of 
hand  to  radial  side. 


256 


FRACTURES   AND   DISLOCATIONS 


ture  and  can  best  be  appreciated  by  a  study  of  the  accompanying 
photoGTaphs.  No  amount  of  text  will  convey  an  idea  of  the  nature 
of  this  deformity  as  readily  as  these  illustrations.  The  radial  sty- 
loid is  usually  raised  above  its  normal  level,  though  in  many  in- 
stances the  displacement  is  not  marked  enough  to  bring  the  tip 
of  the  process  above  the  level  of  the  end  of  the  ulnar  styloid. 
(See  Figs.  370  and  377.)      In   a   ti'aiisverse   Colics'  fracture  with 


Fig.    366. 


Figs.  366  and  367. — Oblique  Colles'  fracture  a  few  minutes  following  injury. 
Forearm  somewhat  resembles  fracture  of  both  bones  of  the  forearm  though  palpation 
discloses  an  intact  ulna.  The  obliquity  of  the  fracture  is  shown  by  the  deformity. 
Note  how  low  and  pronounted  the  anterior  deformity  is  as  compared  with  the  dorsal 
outline.  Compare  this  deformity  with  the  cases  of  transverse  Colles'  fracture  previously 
shown  and  examine  the  accompanying  Rontgenograms.  X-ray  of  this  case  is  shown  in 
Figs.  346  and  347. 

impaction  there  is  generally  rotation  and  angular  deformity  as 
well  as  backward  displacement  of  the  lower  fragment.  Under 
these  circumstances  it  will  be  noted  that  the  radial  side  of  the 
w-rist  is  displaced  further  backward  than  the  ulnar  side,  and  that 
the  axis  of  the  lower  fragment  is  not  parallel  with  the  axis  of  the 
shaft.  Crepitus  is  easily  detected  in  unimpacted  cases.  In  im- 
pacted cases  crepitus  will  be  absent  until  the  impaction  has  been 


FRACTURES   OF   IjOWER   END   OF   RADIUS  257 

broken  up.  In  more  than  half  of  the  eases  of  Colles'  fracture  the 
condition  is  complicated  by  rupture  of  the  triMiis'ular  fibro-earti- 
lage  or  an  equivalent  avulsion  of  its  uhiar  altaehrncnt  so  that  the 
head  of  the  ulna  and  the  lower  radial  fragment  are  separated  and 
the  wrist  broadened.  Fracture  of  the  ulnar  styloid,  so  commonly 
seen  in  Rontgenograms  of  Colles'  fracture,  is  an  evidence  of  the 
action  of  this  ligament.  The  lower  end  of  the  ulna  is,  as  a  rule, 
displaced  forward  as  well  as  inward,  and.  the  absence  of  the 
prominent  ulnar  head  from  the  dorsum  of  the  wrist  is  notice- 
able. 

In  the  usual  Colles'  fracture  the  hand  is  inclined  slightly  to 
the  radial  side  and  the  base  of  the  thenar  eminence  is  higher  than 
normal.  This  radial  displacement  is  sometimes  pronounced,  as 
shown  in  Figs.  356  and  364. 

In  fractures  showing  extensive  comminution  of  the  lower  end  of 
the  radius  the  deformity  is  often  not  characteristic  and  the  condi- 
tion may  be  compound.  When  the  fracture  is  produced  by  an 
auto-crank  kick  the  displacement  is  often  slight  and  the  break  is 
usually  transverse.  A  Colles'  fracture  without  deformity  is  some- 
times seen,  though  the  condition  is  extremely  rare.  Even  when 
the  deformity  is  slight,  it  is,  as  a  rule,  characteristic.  In  oblique 
Colles'  fractures  the  ventral  deformity  is  more  pronounced  and 
lower  than  in  the  transverse  type.  "When  the  break  is  oblique  the 
plane  of  the  fracture  is  usually  similar  to  that  shown  in  Fig.  347, 
and  the  deformity  is  somewhat  different  from  that  seen  in  trans- 
verse Colles'  fracture.  In  oblique  Colles'  fractures  impaction, 
crushing  of  cancellous  tissue  and  comminution  are  rarely  present, 
and  the  rotary  and  angular  elements  in  the  deformity  previously 
described  are  slight  or  absent.  The  lower  fragment  is  displaced 
backward  and  slightly  upward,  but  the  axes  of  the  two  fragments 
are  parallel,  or  nearly  so,  and  the  direction  in  which  the  articular 
surface  looks  remains  unchanged. 

In  Barton's  fracture  the  deformity  is  slightly  lower  and  more 
abrupt  than  in  the  typical  Colles'  fracture.  The  position  of  the 
radial  styloid  remains  unchanged  and  the  wrist  is  not  broadened. 
Crepitus  is  elicited  during  reduction  and  it  will  usually  be  pos- 
sible to  determine  that  the  lower  fragment  includes  only  a  small 
portion  of  the  lower  end  and  posterior  aspect  of  the  radius.  In 
the  reversed  type  of  Barton's  fracture  the  carpus  is  displaced  for- 
ward instead  of  backward,   and  the  radial  styloid   and  posterior 


258 


FRACTURES    AND    DISLOCATIONS 


aspect  of  the  lower  extremity  of  the  bone  are  found  to  be  intact 
and  unduly  ]irominent  when  palpated. 

The  symptojns  of  atypical  fractures  of  the  lower  end  of  the 
radius  vary  \vi1h  Ihe  jiosition  of  the  fracture  ;iiiil  the  direction  of 
tlie  displaeeinent.  Vertical  fractures  of  the  lower  end  of  this 
bone  are  not  accompanied  by  silver-fork  deformity  thoujjh  they 
are  almost  invariabl}'  prodnetive  of  considei-able  broadening'  of  the 
wrist.  An  oblique  fracture  jiassino'  from  the  inner  l)order  of  the 
1  one  to  the  articular  surface  is  often  quite  difficult  to  recojinize 
without  the  aid  of  the  X-ray.     An  example  of  this  type  of  fracture 


Fig.   369. 

Fig.s.  368  and  369. — Two  views  of  an  old  epiphyseal  separation  complicated  by  frac- 
ture of  the  posterior  aspect  of  the  diaphysis.  X-ray  of  this  case  shown  in  Figs.  348  and 
349.  Note  the  low  ventral  deformity  caused  by  the  lower  end  of  the  upper  fragment 
and  the  lateral  prominence  of  the  lower  end  of  the  ulna.  Deformity  resembles  Barton's 
fracture.     Case  first  seen  by  author  six  weeks  following  accident. 


is  show^i  in  Fio-.  329.  In  severe  crushing  injuries  of  the  lower  end 
of  the  radius  the  condition  may  be  flail-like  and  quite  apparent  on 
the  most  superficial  examination. 

The  deformity  accompanying  epiphyseal  separations  is  similar 
to  that  seen  in  the  ordinary  Colles'  fracture.  It  is,  however, 
slightly  lower  and  more  abrupt  in  outline  and  not  accompanied 
by  true  crepitus  unless  complicated  by  fracture.  Epiphyseal  sep- 
arations are  often  complicated  by  fracture  as  shown  in  Figs.  348 
to  353.  "When  the  posterior  aspect  of  the  diaphysis  is  broken  off 
and  displaced  with  the  epiphysis  the  deformity  closely  resembles 


FRACTURES   OF   LOWP^R   END    0[<^    RADIUS 


259 


that  seen  in  oblique  Colles'  fracture.  The  dorsal  deformity  is 
slight  while  the  ventral  deformity  is  pronounced  and  low.  'I'lic 
deformity  accompanying-  an  uncorii[)licated  epi[)}iyseal  sef)ai-;i1ion 
is  shown  in  Fig.  371. 


Fig.    371.  _  Fig.    372. 

Fig.    371. — Uncomplicated   epiphyseal  separation  of  lower  end  of  radius. 
Fi§.    372. — ^Same    case   immediately   following   reduction.      Forearm   partly    secured   to 
ventral   splint. 


260  FRACTTRKS    AND    DISLOCATIONS 

Diagnosis. — Colles'  fracture  is  the  most  common  break  occurring 
ill  the  lower  end  of  the  radius  and  the  symptoms  are,  as  a  rule, 
so  characteristic  that  there  should  be  little  difficulty  in  recognizing 
the  injury.  The  history  of  the  case,  the  typical  silver-fork  de- 
formity, the  elevation  of  the  radial  styloid,  and  the  broadening  of 
the  wrist  are  symptoms  which  should  be  recognized  at  a  glance.  In 
typical  cases  the  diagnosis  of  Colles'  fracture  is  established  with- 
out difficulty  but  the  exact  nature  and  position  of  the  break  and  the 
presence  of  complicating  fractures  of  the  lower  end  of  the  ulna  or 
of  the  carpus  are  often  learned  only  when  the  wrist  is  submitted 
to  the  X-ray.  J\Iany  of  the  salient  features  of  the  fracture  may 
be  determined  by  the  nature  of  the  deformity  (see  "Symptoms," 
page  252),  and  the  surgeon  should  gather  these  data  during  the 
examination.  Prompt  reduction  is  indicated  and  it  is  seldom 
advisable  to  await  the  returns  of  an  X-ray  examination  before 
correcting  the  displacement.  It  is  apparent,  therefore,  that  no 
detail  in  the  physical  examination  should  be  slighted  which  will 
aid  in  disclosing  the  nature  of  the  fracture  or  the  character  of 
the  displacement.  When  a  fracture  in  this  region  is  suspected  the 
surgeon  should  compare  the  injured  parts  with  the  opposite  wrist. 
The  transverse  diameters  of  the  two  wrists  should  be  carefully 
compared. 

The  possibility  of  associated  lesions  must  be  kept  in  mind  while 
examining  fractures  of  the  lower  end  of  the  radius.  Fractures 
of  both  bones  of  the  forearm  near  the  wrist,  luxations  of  the  lower 
tnd  of  the  ulna,  dislocations  of  the  wrist  and  fractures  or  luxa- 
tions of  the  carpal  bones  are  conditions  which  must  be  differen- 
tiated from  fractures  of  the  radius,  and  recognized  as  complications 
when  they  exist.  When  both  bones  of  the  forearm  are  fractured 
near  the  wrist,  crepitus  and  abnormal  mobility  of  the  ulnar  head 
may  be  detected  on  manipulation.  It  is  often  difficult  to  recog- 
nize complicating  fracture  of  the  ulnar  styloid  without  the  aid  of 
the  X-ray.  Dislocations  of  the  wrist  are  extremely  rare  and  are 
seldom  mistaken  for  Colles'  fracture.  Colles'  fracture,  however, 
is  not  infrequently  wrongly  diagnosticated  as  a  dislocation. 
There  should  be  no  excuse  for  this  mistake  if  the  two  deformities 
are  compared.  (See  photographic  comparison  of  the  two  condi- 
tions as  shown  in  Figs.  378  and  379.)  The  deformity  in  disloca- 
tion is  much  lower  and  more  abrupt  in  outline  and  the  extensor 
tendons  stand  out  prominently  as  they  pass  from  the  forearm  to 


FRACTURES    OP    IjOWER   ENJ)    0I<'    RADIUS 


2G 


Pig.    376. — Comparing    the    levels    of    the   two    styloids.      The   radial    styloid    is   raised 
though  its  tip  is  still  at  a  lower  level  than  the  tip  of  the  ulnar  styloid. 


Pig.   377. — Same    comijarison    seen    from    the    dorsal     aspect    of    foreavai. 


262 


FRACTLKKS    AND    DISLOCATIONS 


tlie  hand.  Neither  the  anterior  nor  the  posterior  type  of  luxation 
of  the  ulnar  head  occurs  as  a  complication  of  Colles'  fracture  and 
as  isolated,  injuries  the  symptoms  of  these  two  dislocations  are 
too  characteristic  and  pronounced  to  require  differentiation.  In- 
ward luxation  of  the  ulnar  head,  however,  is  a  very  common  com- 
plication of  Colles'  fracture  and  is  frequently  overlooked.  Broad- 
ening of  the  wrist,  with  inward  and  forward  slumping  of  the  ulnar 
head,  is  indicative  of  this  rumplieation.  On  i)alpatioii,  the  lower 
end  of  the  ulna  is  found  less  firmly  attached  to  the  radius  than 
normal.  It  may  be  possible  to  palpate  the  fractured  styloid.  It 
is  usually  not  difficult  to  difl'ereutiate  fractures  and  luxations  of 


Figs.  378  and  379. — Photogrnpliie  compiivisoii  of  Colles'  fracture  and  backward 
dislocation  of  wrist.  The  dislocation  (lower  picture)  shows  a  much  more  abrupt 
deformity,  except  where  the  tendons  cross  the  articulation  and  the  ventral  deformity 
is   much   lower. 

the  carpus  from  ('olle.-i'  fracture,  yet  lesioixs  of  the  carpus  accom- 
panying Colles'  fracture  are  not  very  uncommon  and  may  be 
overlooked.  The  carpus  should  be  examined  for  deformity  and 
crepitus.  If  doubt  exists  after  the  wrist  is  thoroughly  examined 
it  is  advisable  to  resort  to  the  X-ray.  Thus  the  diagnosis  is  estab- 
lished, the  details  of  the  lesion  or  lesions  are  disclosed  and  the 
parts  will  have  been  subjected  to  the  least  possible  manipulation 
and  trauma.  When,  on  the  other  hand,  the  presence  of  fracture 
is  apparent  on  examination  and  the  deformity  has  been  imme- 
diately corrected,  a  Rontgenogram  should  be  made  to  determine 
the  completeness  of  reduction,  to  verify  the  diagnosis  and  to  ex- 
clude associated  lesions  of  adjoining  bones. 


FRACTURES   OF   LOWER   END    OF   RADIUS 


263 


Th(3  differentiation  of  Colles'  fracture  from  simple  sprain  of  the 
wrist  is  at  times  more  confusing  than  would  at  first  appear.  Swell- 
ing of  the  parts  and  distention  of  the  synovial  slicnths  following 


Fig.   381. 
Figs.  380  and  381. — Radial  and  ulnar  views  of  Colles'  fracture  just  before  reduction. 
(See  Figs.   382   and  383.) 


Figs.  382   and  383. — Two  methods  of  grasping  the  wrist  in  reducing  Colles'  fracture. 
The  arrows  indicate  the  lines  of  force  employed. 

a  sprain  may  simulate,  to  some  extent,  the  deformity  of  Colles' 
fracture.  Unless  one  is  familiar  with  the  condition  and  a  careful 
examination  is  made,  a  sprain  may  be  mistaken  for  a  fracture,  or 


264 


FRACTURES   AND    DISLUCATIONS 


vice  versa.  Tlie  soft  crepitation  of  a  synovitis  should  not  be  mis- 
taken for  the  true  crepitus  aceouipanying  fracture.  Synovial  crepi- 
tation is  limited  to  the  course  of  the  tendons  and  is  not  produced 
by  sti-('ss  (Ml  tlu'  lower  end  of  the  radius. 

Treatment. — Reduction  should  be  effected  at  the  earliest  possible 
moment.  The  sooner  the  deformity  is  corrected  the  less  pro- 
nounced   will    he   the   subsequent    tiauniatic    reaction.     Reduction 


Fig.  384. — Shows  the  principles  to  be  followed  in  reducing  the  usual  transverse 
impacted  Colles'  fracture.  A.  Section  of  normal  radius.  B.  Transverse  impacted  Col- 
les'  of  common  type.  G.  shows  lower  fragment  forced  back  into  position.  Note  wedre- 
shaped  space,  the  result  of  crushed  cancellous  tissue.  If  the  fragment  is  released  in 
this  position  deformity  will  recur  since  the  posterior  layer  of  compact  tissue  is  not 
engaged.  D.  shows  distal  fragment  forced  forward,  thus  obtaining  an  engagement 
which  prevents  recurrence  of  deformity.  E.  represents  a  form  of  fracture  in  which  ihe 
posterior  cortical  layer  of  the  distal  fragment  is  broken  up.  F.  shows  the  use  of  pads 
on   the   splints   to   maintain   reduction    when   the   fracture   is   of    the   type   shown    in   E. 


is  best  accomplished  under  anesthesia.  In  many  cases  a  satis- 
factory adjustment  of  the  frag-ment  can  be  accomplished  without 
this  aid,  yet  with  the  patient  unconscious  and  free  from  pain  the 
surgeon  is  better  enabled  to  obtain  an  accurate  reposition  of  the 
fragment.  If  the  fracture  is  impacted  considerable  force  may  be 
needed  to  free  the  lower  fragment  so  that  it  may  be  replaced.  In 
oblique  Colles'  fracture  the  lower  fragment  can,  as  a  rule,  be  slid 


FRACTURES   OF   LOWER  END   OF   RADIUS 


265 


back  into  position  ])ut  the  derormity  is  lik'cly  to  recur  if  tfic 
fragments  are  not  firinly  engaged  following  reduction.  For  this 
reason  the  fractured  surfaces  should  be  forced  together  after  the 
fragment  has  been  replaced.  When  the  fracture  is  transverse  and 
there  is  impaction  and  crushing  of  cancellous  tissue,  reduction 
requires  a  somewhat  different  manipulation.  In  this  form  of 
fracture  the  fragments  must  be  separated  by  traction  and  counter- 
traction  to  pull  the  lower  end  of  the  upper  fragment  out  of  the 
lower  fragment.  When  this  has  been  accomplished  the  lower  frag- 
ment is  pulled  downward  and  forward  and  the  deformity  slightly 
over-corrected.     In  this  way  the  layer  of  compact  tissue  on  the 


UfcTx-toCa^ 

5-joii>ya;: 

Fig.   385. 

^/kn,</<rt/ 

^pl^v 

Pig.    386. 

Figs.  385  and  386. — Diagi-ams  of  splints  used  in  the  treatment  of  fracture's  of 
the  forearm.  The  ventral  splint  is  cut  out  to  avoid  pressure  on  the  thenar  eminence. 
(See  Figs.    307   to   312.) 


Fig.    387. — Shows    a    dorsal   splint,    cut-out    opposite    the    head    of    the    ulna.      This    is 
rarely  needed  if  a  heavy  enough  layer  of  padding  is  used. 

posterior  surface  of  the  lower  fragment  is  engaged  against  the 
corresponding  layer  in  the  upper  fragment  and  redisplacement  is 
prevented.  If  this  is  not  accomplished  the  deformity  will  recur 
since  the  lower  end  of  the  upper  fragment  will  drop  back  into  the 
space  in  the  lower  fragment  corresponding  to  the  crushed  cancel- 
lous tissue.  The  accompanying  diagrams  (Fig.  384)  illustrate  the 
manner  in  which  deformity  recurs  and  the  necessity  for  slightly 
over-correcting  the  displacement.  Manipulations  such  as  shown  in 
Figs.  382  and  383  are  recommended  in  correcting  the  displacement 
but  the  most  important  requisite  for  proper  reduction  is  a  clear 
understanding  on  the  part  of  the  surgeon  concerning  the  nature 
of  the  break  and  the  relative  positions  of  the  fragments. 

The  grip  shown  in  Fig.  383  usually  works  well  in  the  oblique 
type  of  Colles'  fracture  while  the  one  shown  in  Fig.  382  is  most 


266 


FRACTT^RES   AND   DISLOCATIONS 


eflfieit'iit  wlu'ii  llie  break  is  transverse  and  impaction  exists.  If  the 
lower  radio-ulnar  articulation  remains  intact  reduction  can  some- 
times be  ett'eeted  by  strong'  ulnar  Hexion  of  the  wrist.  By  this 
method  the  radio-nlnar  articulation  is  used  as  a  fulciuin  in  forcing 
the  lower  radial  fragment  back  into  position.  Care  shoidd  be 
exercised,  however,  not  to  place  more  strain  on  the  articulation 
than  it  will  stand  as  otherwise  it  may  be  broken  up,  thus  increasing 
the  damage  instead  of  correcting  the  deformity.  After  the  dis- 
placement of  the  radial  fracture  has  been  corrected  lateral  pressure 
should  be  exerted  on  the  lower  end  of  the  ulna  to  force  tlic  ulnar 
head  home  against  the  sigmoid  cavity  of  the  radius;  thus  correct- 
ing the  lateral  and   forward  displacement   of  the   ulna. 


Fig.    388. — The   Walker    splint. 
the  treatment  of  Colles'   fracture. 


IMade    in    "rights"    and    "lefts"    and    in    five   sizes   for 


Numerous  splints  have  been  devised  to  prevent  recurrence  of 
deformity  and  they  are  of  some  advantage,  though  their  value 
has  been  greatly  exaggerated.  Special  padding  and  splints  of 
special  design  should  never  be  used  with  the  idea  of  actively  cor- 
recting deformity.  The  displacement  should  be  overcome  as  fully 
as  possible  at  the  time  of  reduction  and  the  most  that  should  be 
attempted  in  fixation  of  the  parts  is  to  prevent  the  recurrence  of 
the  deformity.  The  various  types  of  dressing  which  have  been 
employed  in  the  fixation  of  Colles'  fracture  are  too  numerous  to 
mention.  The  most  important  element  in  the  treatment  of  these 
cases  is  to  secure  an  accurate  reduction  and  firm  engagement  of 
the  fragments,  and  to  then  protect  the  parts  from  strains  which 


FRACTIJIUOS   OK    hOWER   END    OF   RADIUS 


267 


might  disturb  the  fragments.  Tho  nature  of  the  fixation  employed 
will  depend  on  the  tendency  to  recurrence  of  deformity  and  the 
age  and  temperament  of  the  patient.  An  adult  may  in  most  cases 
be  depended  upon  to  avoid  disturbing  the  parts  during  the  after- 
treatment  and  to  follow  the  instructions  given  by  the  surgeon. 
On  the  other  hand  an  active  child  cannot  be  trusted  and  the  wrist 
should  be  so  firmly  dressed  that  the  parts  are  not  likely  to  be 
accidentally  disturbed. 

When  therefore  a  solid  engagement  can  be  obtained  in  .a  depend- 
able adult  the  wrist  may  be  encircled  with  a  strip  of  adhesive 
plaster  and  the  forearm  carried  in  a  sling.  The  hand  should  not 
be  supported  by  the  sling  but  is  allowed  to  hang  dependent  from 


Fig.    3f 
adhesive. 


Fig.    389'.  Fig.    390.  Fig.    391. 

3. — Short  splints   applied   to   wrist   and   held   in   position   by   circular   strap   of 


Fig.  390. — Shows  proper  position  of  wrist  and  hand.  Wrist  is  carried  in  ulnar 
flexion. 

Fig.  391. — Shows  improper  method  of  carrying  wrist  and  hand.  Forearm  pronated 
and  wrist  flexed. 

the  wrist  in  a  position  of  ulnar  fiexion.  Excellent  results  can  be 
obtained  in  this  way,  provided  a  solid  engagement  of  the  fragments 
has  been  secured  and  the  patient  follows  directions  and  does  not 
disturb  the  parts.  If  a  short,  properly  padded  dorsal  splint  is 
secured  in  position  with  a  circular  strip  of  adhesive  plaster  the 
immobilization  will  be  found  more  secure  than  that  obtained  by 
the  encircling  strip  of  adhesive  alone.  When  the  short  dorsal 
splint  is  employed  appropriate  padding  should  be  placed  between 
the  adhesive  and  the  ventral  surface  of  the  wrist.  In  instances  in 
which  there  has  been  much  comminution  and  the  tendency  to  recur- 
rence of  deformity  cannot  be  overcome  during  reduction  this 
method  is  entirely  too  insecure  and  should  not  be  employed.     Under 


268  FRACTURES   AND   DISLOCATIONS 

these  c'ireiinistances  the  antci-ior  and  posterioi'  splints  siicli  as  used 
in  the  treatment  of  fraeturcs  of  tlie  forearm  will,  in  most  eases, 
serve  the  jnirpose  better.  Heavy  paddin<>-  of  the  posterior  splint 
below  the  plane  of  fracture  and  of  the  anterior  si)lint  above  the 
break  will  tend  to  prevent  the  return  of  the  silver-foi-k  deformity. 
The  best  material  for  this  sjieeial  paddinu'  is  saddler's  felt  which 
may  be  obtained  from  any  harness  shop.  It  is  elastic,  holds  its 
shape  well  and  may  be  cut  into  pads  of  desired  i)roportions.  The 
splints  should  be  a  little  broader  than  the  forearm  in  its  thickest 
part  and  should  be  loosely  enough  applied  to  avoid  constriction. 
The  forearm  should  not  be  bandaged  before  the  splints  are  placed 
in  position.  The  padding  is  never  used  with  the  expectation  of 
actively  forcing  the  fragments  back  into  i)lace  but  only  for  the 
jmrpose  of  ])reventing  redisplacement.  One  splint,  usually  the 
anterior,  is  secured  in  place  by  strips  of  adhesive.  The  opposite 
splint  is  then  applied  and  may  be  removed  separately  during  the 
after-treatment  without  depriving  the  fracture  of  the  support 
offered  by  the  opposite  splint.  (See  Figs.  307  to  312.)  In  this 
way. the  anterior  splint  supports  the  forearm  and  wrist  while  the 
surgeon  is  inspecting  the  parts  and  readjusting  the  dressing. 
It  is  of  paramount  importance  that  free  circulation  be  present  after 
the  dressings  are  in  place.  During  the  first  few  days  following 
the  injury  due  allowance  should  be  made  for  the  swelling  which 
comes  with  traumatic  reaction.  Constriction  may  be  readily  de- 
tected by  examining  the  nails.  The  dangers  of  too  tight  bandaging 
and  strangulation  of  the  forearm  have  already  been  mentioned 
under  "Fractures  of  Bones  of  the  Forearm."  The  Bond  splint 
and  others  of  the  same  type  which  maintain  the  wrist  in  a  position 
of  ulnar  flexion  are  of  service  in  some  cases  but  their  value  has 
been  greatly  overestimated.  It  has  been  customary  for  years  to 
consider  the  position  of  the  hand  as  exerting  great  influence  on  the 
recurrence  of  deformity.  As  a  matter  of  fact  there  are  a  few 
conditions  in  which  the  position  of  the  hand  affects  the  position  of 
the  fragment,  but  in  nearly  all  fractures  in  this  region  the  prime 
requisite  in  avoiding  the  recurrence  of  deformity  is  the  proper 
reduction  of  the  deformity  and  firm  engagement  of  the  fragments. 
If  the  lower  radio-ulnar  articulation  remains  intact  ulnar  fiexion 
will  tend  to  hold  the  lower  radial  fragment  in  reduction,  but  if 
the  articulation  has  been  broken  up,  this  position  will  only  increase 
the  displacement  of  the  ulnar  head.     Comminution  of  the  lower 


FRACTURES    OF    l.OWKR   END    OF    RADIUS  269 

end  of  the  radius,  crushing  of  the  cancellous  tissue  in  this  region 
and  ohliquity  in  the  plane  of  fracture  are  the  inost  eornraou  causes 
of  recurrence  of  deformity  following  proper  redu(;tion,  and  the 
position  of  the  hand  during  the  after-treatment  has  little  influence 
in  maintaining  reduction  when  these  conditions  exist.  Flexion  of 
the  wrist  places  the  extensor  tendons  on  the  stretch  and  they  are 
thus  supposed  to  exert  a  splinting  action  on  the  fragments. 
Ulnar  flexion  throws  more  strain  on  the  ulna  and  relieves  the 
radius,  to  some  extent,  of  the  shortening  effect  of  the  muscles  of 
the  forearm.  It  is  questionable,  however,  if  either  of  these  posi- 
tions makes  enough  difference  to  be  of  practical  importance  in  the 
treatment  of  Colles'  fracture.  Extensive  comminution  of  the  lower 
end  of  the  radius  renders  the  fragments  difficult  to  maintain  in 
good  reduction  and  it  is  here  that  ulnar  flexion  will  be  found  of 
most  value,  provided  the  lower  radio-ulnar  articulation  has  not 
been  broken  up. 

The  reduction  of  Barton's  fracture  involves  the  same  principles 
as  already  described  in  correcting  the  deformity  of  Colles'  frac- 
ture. In  atypical  fractures  of  the  lower  end  of  the  radius  the 
surgeon  must  be  guided  by  the  nature  of  the  fracture  and  the 
character  of  the  displacement.  If  the  type  of  the  fracture  is 
fully  appreciated  the  surgeon  will  be  better  able  to  correct  the 
deformity  and  hence  the  value  of  the  X-ray,  especially  in  instances 
in  which  difficulty  is  experienced  in  correcting  the  displacement. 
Occasionally  cases  are  encountered  in  which  reduction  cannot  be 
accomplished  wdthout  resorting  to  open  incision.  The  local  use  of 
the  ice  bag  during  the  first  twenty-four  to  forty-eight  hours  wall 
be  found  of  great  service  in  controlling  the  traumatic  reaction, 
especially  in  cases  in  Mdiich  the  causative  trauma  has  been  severe. 

Operative  Treatment. — Operation  is  sometimes  indicated  when 
a  satisfactory  reduction  cannot  be  otherwise  obtained.  A  small 
fragment  of  bone  may  become  interposed  between  the  fractured 
surfaces  and  require  removal  before  the  deformity  can  be  cor- 
rected. Direct  reposition  of  the  fragments  through  the  incision 
will  be  all  that  is  required  in  most  cases. 

The  common  fracture  of  the  lower  end  of  the  radius  is  best  ap- 
proached through  a  longitudinal  incision  on  the  outer  side  of  the 
wrist.  This  incision  exposes  the  radial  artery  and  nerve  and 
the  extensors  of  the  thumb.  Under  cover  of  the  posterior  lip  of 
the  wound  will  be  found  the  radial  extensors  of  the  carpus.     The 


270 


KRACTI'RES    AND    DISLOCATIONS 


course  of  tlio  radial  artery  is  sometimes  anomalous,  winding:  around 
the  lower  fourth  of  the  radius  instead  of  passing  throuuli  llie  ana- 
tomical snuff-box.  This  condition  may  be  recognized  by  palpating 
the  arter}^  even  before  the  incision  is  made.  Oblique  Colles'  frac- 
ture and  some  of  the  atypical  breaks  seen  in  the  lower  end  of  the 
radius  may  need  some  form  of  internal  fixation  to  prevent  recur- 
rence of  deformity.  The  placing  of  this  material  will  depend  en- 
tirely on  the  nature  of  the  fracture  and  the  character  of  the 
displacement.     In    oblique    fractures   which    cannot    otherwise   be 


Fig.    392. 


Fig.    393. 


Fig.  392. — Skiagram  showing  radial  epipliysis  displaced  to  the  radial  side  and  a 
portion  of  the  shaft  of  the  bone  carried  with  it.      (Haubold — Journal  A.  31.  A.) 

Fig.  393. — Skiagram  showing  the  detached  fragment  nailed  to  the  shaft  of  tlie 
bone.      (Haubold — Jotirnal    A.    M.    A.) 


maintained  in  reduction  a  small  loop  of  wire  passing  through  the 
fragments  will  often  accomplish  all  that  is  desired.  In  instances 
of  pronounced  radial  displacement  of  the  lower  fragment  a  satis- 
factory fixation  may  be  obtained  in  some  cases  by  nailing  the  lower 
fragment  to  the  upper  as  shown  in  Fig.  393.  Ei)iphyseal 
separations  seldom  require  operative  intervention.  Occasionally  an 
untorn  periosteum  may  offer  resistance  to  the  reduction  of  a  dis- 
placed epiphysis  and  it  may  be  necessary  to  divide  this  tissue  be- 
fore the  deformity  can  ])e  corrected.  Recurrence  of  deformity  in 
an  epiphyseal  separation  may  be  due  to  a  complicating  fracture  of 


PRACTURI'^S    OK    ];()WI';K    I'.NU    OF    liADIHS  271 

the  diaphysis  (see  Fig.  349)  and  to  prevent  this  tciidciiey  to  dis- 
placement it  may  be  necessary  to  wire  the  fragments  of  the  di- 
aphysis together. 

Compound  fractures  of  the  lower  end  of  the  radius  should  be 
treated  according  to  the  principles  as  laid  down  under  the  heading 
of  ''Treatment  of  Compound  Fractures  and  Dislocations,"  page 
789. 

In  some  cases  of  comminution  of  the  lower  end  of  the  bone  a 
circular  wire  will  so  bind  the  fragments  together  that  the  com- 
minuted bony  area  is  brought  closer  together  and  the  deformity 
lessened.  In  other  cases  the  comminution  may  be  so  extensive  that 
operative  procedure  is  not  advisable. 

Old  cases  of  CoUes'  fracture  with  deformity  and  pronounced  loss 
of  function  may  require  operation  for  the  correction  of  the  de- 
formity and  the  breaking  up  of  adhesions.  This  operation,  how- 
ever, should  not  be  undertaken  without  a  careful  study  of  the  case 
including  an  X-ray  examination.  •  One  should  determine,  as  far  as 
possible,  how  much  of  the  loss  of  function  is  due  to  the  deformity, 
and  how  much  is  the  result  of  joint  and  tendon  adhesions,  and 
whether  or  not  there  is  a  rarifying  osteitis  of  the  lower  end  of 
the  radius.  The  loss  of  function  is  more  often  due  to  adhesions 
than  to  deformity,  and  hence  the  greatest  good  will,  in  most  cases, 
result  from  a  breaking  up  of  these  adhesions  under  anesthesia, 
Mdthout  incision  of  the  parts  or  refracture  of  the  bone.  Kecent 
cases  may  be  refractured  without  incision,  provided  the  condition 
is  not  more  than  three  or  four  weeks  old.  It  is  usually  best,  how- 
ever, to  produce  refracture  through  an  incision  since  more  accurate 
work  can  be  done  in  this  way. 

After-Treatment. — The  case  should  be  seen  daily  for  the  first  few 
days  to  adjust  the  dressings  to  the  varying  size  of  the  forearm 
and  wrist  during  the  onset  and  subsidence  of  traumatic  swelling. 
Recurrence  of  deformity  should  be  watched  for  and  corrected  if 
it  occurs.  Disturbance  of  the  circulation  or  pain  (especially  in  the 
region  of  the  three  pressure  points)  calls  for  readjustment  of  the 
dressings  and  inspection  of  the  region  of  fracture.  The  three 
pressure  points  just  referred  to  are  the  head  of  the  ulna,  the  bases 
of  the  second  and  third  metacarpals  and  the  thenar  eminence. 
Undue  pressure  at  these  points  may  lead  to  sloughing  of  the  soft 
tissues  which  is  a  painful,  annoying  and  serious  complication.  The 
lower  end  of  the  anterior  splint  should  be  cut  away  on  the  radial 


272 


FRACTURES   AND    DISLOCATIONS 


side  to  avoid  pressure  on  the  thenar  eniinenee  as  already  described 
in  the  treatment  of  "Fractures  of  the  Radial  and  Ulnar  Shafts" 
on  page  224.  The  posterior  splint  should  be  well  padded  oppo- 
site the  hand  and  wrist  to  avoid  undue  pressure  on  the  licad  of  the 
ulna  and  the  bases  of  the  metacarpals.  If  unusual  difficulty  is 
experienced  in  avoiding  pressure  on  these  points  the  posterior  splint 
may  have  holes  drilled  through  it  corresponding  to  these  promi- 
nences and  the  padding  reapplied.  Pain  should  not  be  pronounced 
after  six  or  eight  hours.  The  fingers  must  be  moved  daily  during 
the  entire  course  of  the  treatment.  Immobilization  of  the  fingers 
is  folloAved  by  a  loss  of  function  which  is  probably  worse  than  the 
sum  total  of  untoward  symptoms  seen  in  untreated  cases.  It  is 
much  more  important  to  secure  a  good  functional  result  than  it 
is  to  have  the  fragments  in  perfect  anatomical  relation,  and  it  must 


Fig.  394. — Colles'  fracture  al)out  twenty-four  hours  following  accident.  Displace- 
ment of  fragrment  slight  b\it  traumatic  reaction  pronounced.  Swelling;  masks  deformity 
to  ^eat  extent.  It  is  during  the  first  twenty-four  or  forty-eight  hours  that  there  is 
danger  of  the  circulation  being  interfered  with  as  a  result  of  the  forearm  swelling  within 
the  dressings.  It  is  therefore  imperative  that  the  first  dressings  be  loosely  applied 
and  the  member  closelv  watched  for  signs  of  strangulation.  (See  Figs.  318,  319  and 
320.) 

not  be  forgotten  that  function  depends  more  on  the  early  and  free 
passive  motion  of  the  fingers  and  thumb  during  treatment  than  on 
anything  else.  The  older  the  patient  the  more  important  is  pas- 
sive motion.  At  the  end  of  a  week  or  ten  days  the  posterior  splint 
may  be  dispensed  with,  and  both  may  be  discarded,  in  the  average 
case,  two  weeks  from  the  time  of  accident.  A  strip  of  adhesive 
may  then  be  placed  about  the  wrist  and  the  forearm  carried  in  a 
sling  with  the  hand  hanging  dependent  in  a  position  of  ulnar 
flexion.  In  some  cases  the  posterior  splint  may  be  retained  for  a 
week  or  ten  da^'s  longer  as  a  precaution  against  external  violence. 
This  is  particularly  advisable  in  the  treatment  of  children.  Old 
patients  should  be  allowed  more  time  for  union  to  take  place.     Un- 


FRACTURES   OP   LOWER   END    OF    RADIUS 


273 


necessary  strain  to  the  wrist  should  be  avoided  for  a  month  or 
more  following  removal  of  dressings,  but  the  patient  should  be 
urged  to  use  wrist  and  fingers  freely  so  that  function  may  be  fully 
restored.  In  favorable  cases  gentle  passive  motion  of  the  wrist 
should  be  begun  as  early  as  the  end  of  a  week  or  ten  days  follow- 
ing injury  and  kept  up  daily  until  union  is  present  and  function 
restored.  Hot  water  and  massage  are  of  service  in  restoring  the 
parts  to  normal  free  function  and  should  be  persisted  in  until 
recovery  is  complete.  The  after-treatment  of  atypical  fractures 
and  epiphyseal  separations  of  the  lower  end  of  the  radius  involves 
the  same  principles  as  already  given  in  the  after-care  of  a  typical 
Colles'  fracture. 

Prognosis. — Bony  union  is  well  established  at  the  end  of  three 
weeks  in  the  healthy  young  adult.     Complete  supination  will  usu- 


Fig.    395. 


Fig.   396. 

Figs.  395  and  396. — Characteristic  deformity  following  incomplete  reduction  of  an 
oblique  Colles'  fracture.  Note  slight  silver-fork  deformity  and  transverse  thickening 
of  the  wrist  which  results  from  rapture  of  the  lower  radio-ulnar  ligament  of  fracture 
of  ulnar  styloid.  Lateral  and  ventral  slumping  of  lower  end  of  ulna  apparent.  Case 
first  seen  by   author   at  time  this   photograph  was   taken. 

ally  be  the  last  motion  to  be  fully  restored;  this  is  particularly 
true  in  instances  in  which  the  lower  radio-ulnar  articulation  has 


274 


KKACTrUKS    AND    DISLOCATIONS 


Fie.  397. — Aiuitlior  ca.so  of  broadened  wrist  following'  incomplete  reduction  of 
Colles'  fracture.  Patient  present.s  liimself  for  treatment  becau.se  of  slow  recovery  and 
inability  to  use  hand.  "Wrist  stiff,  painful,  etc.  Case  first  seen  by  author  at  time  this 
photograph    was    taken. 


Fig.  398. — Another  case  of  slow  and  incomplete  recovery  following;  Colles'  fracture. 
In  this  ease  the  reduction  has  been  excellent  but  the  after-treatment  has  been  faulty 
in  that  the  patient's  hand,  wrist  and  fingers  were  completely  immobilized  for  a  period 
of  six  weeks.  Adhesions  between  the  joint  surfaces  and  within  the  tendon  sheaths  have 
resulted  and  the  X-ray  discloses  an  osteitis  of  the  carpus.  Patient  55  years  of  age. 
(See  Fig.  399.)      Case  first  seen  by  author  at  the  time  this  picture  was  taken. 


Fig.  399. — Osteitis  of  (In-  carinis  and  l>asrs  (jf  llic  jiu-lacarpals  lollnwiii-  .i  Colles' 
fracture  in  which  the  condition  was  treated  by  prolonged  imniol)ilizati()n.  Tins  condi- 
tion is  not  uncommon  in  patients  past  middle  life  in  which  the  parts  are  immobilized 
for  too  long  a  period.  .V  condition  such  as  this  is  very  much  easier  to  avoid  than  it  is 
to  treat,  after  it  has  become  established.  It  should  be  remembered  that  thf  possibility 
of  fracture  in  breaking  up  adhesions  is  greater  in  a  case  like  this  than  it  would  be  if  the 
carpal  bones  were  normal. 


FRACTURES    OF    liOWRR   FND    OF    RADiriS 


275 


been  broken  up  or  in  cases  in  which  the  fracture  has  entered  the 
sigmoid  cavity  of  the  radius.  ]n  older  persons  restoration  of  func- 
tion is  much  slower  and  adhesions  in  and  about  the  tendon  sheaths 
and  in  the  wrist  joint  are  more  prone  to  occur  and  are  important 
elements  in  restricting  motion.     The  complete  restoration  of  func- 


Fig.   401. 

Figs.  400  and  401. — Contracture  of  the  hand  following  Colles'  fracture.  Nerves 
injured  either  at  the  time  of  the  accident  or  during  the  after-treatment  from  too  tight 
bandaging.  Indication  of  beginning  contracture  first  noted  at  the  time  the  splints  were 
removed.      First  seen  by   author   about  eighteen  months   after  the   injury. 


tion  depends  more  on  the  early  and  persistent  use  of  passive  mo- 
tion than  on  the  anatomical  redviction  of  the  displacement.  The 
prognosis,  therefore,  is  more  or  less  directly  dependent  on  the 
proper  use  of  passive  motion  during  the  after-treatment.  In  some 
cases  joint  and  tendon  adhesions  and  rarifj'ing  osteitis  develop  in 
spite  of  the  most  careful  treatment  (see  Fig.  399)  but  tliese  con- 


276  FRACTURES   AND   DISLOCATIONS 

ditioiis  are  fortunately  rare  in  cases  receiving  tlie  proper  care  dur- 
ing the  after-treatment.  Restricted  motion  of  the  wrist  and 
fingers,  and  slight  pain  especially  in  the  region  of  the  ulnar  styloid, 
are  conditions  which  may  persist  "for  months  but  will,  as  a  rule, 
pass  oft'  with  massage  and  hot  applications.  The  more  faithfully 
passive  motion  is  carried  out  during  the  time  the  wrist  is  immobi- 
lized the  less  pronounced  will  be  these  annoying  sequehe.  Destruc- 
tion of  bony  tissue  izi  the  lower  end  of  the  radius,  such  as  occurs 
in  impaction  and  extensive  comminution,  may  render  accurate  re- 
duction, even  under  operation,  impossible  and  hence  some  deformity 
will  result,  but  this  does  not  necessarily  mean  any  considerable  loss 
of  function. 

An  ordinary  uncomplicated  Colles'  fracture  which  is  properly 
reduced  and  treated  should  be  followed,  in  a  healthy  adult,  by 
complete  restoration  of  function.  In  older  patients  a  perfect  func- 
tional result  will  be  more  difficult  to  obtain.  In  atypical  fractures 
of  the  lower  end  of  the  radius  the  prognosis  will  vary  with  the 
severity  and  character  of  the  fracture.  Uncomplicated  epiphyseal 
separations  of  the  lower  end  of  the  radius  should  be  followed  by 
perfect  results  both  functionally  and  anatomically  if  the  epiphysis 
is  properly  reduced.  Disturbances  in  the  growth  of  the  radius 
are  rarely  seen  following  epiphyseal  separations,  if  anything  like 
a  perfect  reduction  has  been  obtained.  Even  in  cases  in  which 
pronounced  displacement  is  allowed  to  persist  defective  growth  is 
rarelv  seen, 


CHAPTER  XX. 

INJURIES  TO  THE  CARPUS. 

Under  this  heading  is  included:  radio-carpal  luxations  (com- 
monly spoken  of  as  dislocations  of  the. wrist),  meclio-carpal  luxa- 
tions, and  fractures  and  dislocations  of  the  individual  carpal  bones. 

Surgical  Anatomy. — The  strength  of  the  wrist  is  such  that  when 
subjected  to  violence  fracture   is  more  likely  to  occur  above  or 


Fig.   403. 


Figs.  402   and  403. — Ventral   and  dorsal  views  of  ligaments  of  hand.      U..  nlna  ;   R., 
radius;    TJ.N.,  uncinate;    P.,  pisiform;   T.,  trapezium. 

below  this  region  than  in  the  carpus  itself.     The  ligaments  bind- 
ing the  bones  of  the  forearm  to  the  carpus,  those  between  the 

277 


278 


FRACTURES   AND    DISLOCATIONS 


carpus  iiiiil  iiu't;ic;irpus,  and  the  inter-cai'pal  ligaments  are  all 
licax y  ami  strong  but  the  main  strength  of  the  wrist  is  dependent 
on  Iho  numerous  and  heavy,  tendons  which  pass  from  the  forearm 
to  the  liand,  and  are  bound  firmly  to  the  bones  by  the  annular 
ligaments  and  the  fibrous  compartments  through  which  they  run. 
It  should  be  remembered  that  though  the  carpus  is  actuated  by 
the  flexors  and  extensors  passing  from  the  forearm  to  the  hand, 
only  one  of  these  muscles  is  inserted  into  the  carpus.  The  flexor 
carpi  ulnaris  is  inserted  into  the  pisiform  but  since  this  bone  is 


Fi5.  404. — lidiHs  (if  niinrnil  wrist.  1  M,  2  M,  3  M.  J  ^f ,  ami  5  M  indicate  metn- 
carpals:  Tm.,  Traijeziuin  ,  Td..  Tiap'-zoid;  O.  M.,  Cs  Magnum;  V.,  Unciform;  C,  Cunei- 
form;  P.,  Pisiform;    SI.,   Semilunar;    Se.,   Scaphoid';    VI. ,   Ulna;   R.,   Radius. 


functionally  a  sesamoid  bone  and  not  truly  a  bone  of  the  carpus 
we  may  consider  the  carpus  as  free  from  the  insertions  of  the 
muscles  of  the  forearm.  Thus  the  carpus  is  actuated  indirectly 
through  the  metacarpal  bones.  Some  of  the  intrinsic  muscles  of 
the  hand  arise  from  the  ventral  surface  of  the  lower  row  of  carpal 
bones,  but  their  action  is  on  the  metacarpus  rather  than  the  carpus. 
The  radio-carpal  or  wrist  joint  is  a  condyloid  articulation.  The 
articular  surface  of  the  lower  end  of  the  radius  and  the  inferior 
surface  of  the  triangular  fibro-cartilage  form  the  socket,  while  the 
upper  surfaces  of  the  scaphoid,  semilunar  and  cuneiform  bones 


INJURIES   TO    THE    CARPTJR 


270 


form  the  condyle.  Motion  of  this  articulation  is  possible  in  every 
direction  except  axial  rotation.  The  plane  of  the  radio-carpal 
joint  is  on  a  level  with  the  tip  of  the  ulnar  styloid.  Luxations  of 
this  joint  may  take  place  in  any  direction  but  are  extremely  rare; 


Fig.   405. 


Fig.   406. 


Fig.   405. — Old  Colles'   fracture.      Ti-iangulare  present.      Indicated  by   arrow. 
Fig.    406. — Anotlier   old   Colles'    fracture   with    anomalous   triangulare. 


Fig.   40  7. 


Fig.   408. 


Fig.   407. — Example  of   anomalous  centrale. 

Fig.  408. — Space  in  carpus  corresponding  to  site  of  centrale.  Anomalous  condition 
present  though  the  embryonic  elements  entering  into  formation  of  centrale  show  no 
signs  of  ossification. 

only  a  few  cases  of  each  type  having  been  recorded.  Colles'  frac- 
ture is  frequently  mistaken  for  dislocation  of  the  wrist,  and  the 
cases  of  this  luxation  reported  prior  to  the  advent  of  the  X-ray 
are  particularly  untrustworthy.  Dislocation  of  the  wrist  compli- 
cated by  fracture  of  the  lower  end  of  the  radius  is  not  nearly  as 


280 


FRACTURES   AND   DISLOCATIONS 


uncommon  as  tlie  pure  luxation.  AVIumi  the  carpus  is  displaced 
backward  and  up\vard  and  tlie  i)osterior  lip  of  the  radius  is  broken 
off  and  displaced  with  the  carpus,  the  condition  is  known  as  Bar- 
ton's fracture  and  has  been  desarihed  under  "Fractures  of  the 
Lower  End  of  the  Radius."  When  the  i'ever>se  condition  obtains, 
that  is,  when  the  ventral  lip  of  tlie  radius  is  broken  off  and  dis- 


Pig.   409. — Old    united    fracture    of    scaphoid. 


Fig.    410. — Fracture   of    semilunar. 


Fis;.   411. — Fracture    of    scaphoid. 


placed  forwai'd  and  upward  with  tlie  carpus,  it  is  known  as  a 
"reversed  Barton's  fracture.""  I^ateral  luxations  of  this  joint, 
either  with  or  without  fracture,  are  too  rare  to  be  considered  as  a 
type.  It  is  probable  that  a  large  proportion  of  the  reported  cases 
of  luxation  of  the  radio-carpal  joint  (especially  those  not  examined 
with  the  X-ray)  have  in  reality'  been  Colles'  fractures  or  at  least 
fracture-luxations  of  Barton's  type. 


IN.TTTRTER    TO    TTIE    CARPTJR 


281 


Fig.  412. — Fractured  cuneiform. 


Fig.    413.  Fig.    414. 

Figs.   413    and   414. — Anteroposterior    and   lateral  views   of   luxated   semilunar. 


282 


FRACTURES   AND   DISLOCATIONS 


Luxations  of  the  mcdio-carpal  articulation  probably  never  occur 
as  a  pure  dislocation,  following  accurately  the  lines  of  the  medio- 
carpal  articulation.  They  are  usually  complicated  by  fracture  of 
one  or  more  of  the  carpal  bones  with  displacement  of  the  fragments. 

Isolated  fractures  and  luxations  of  the  carpal  bones  are  not 
very  uncommon  injuries  and  are  now  known  to  accompany  frac- 
tures of  thi'  lower  end  of  the  forearm  more  frequently  than  was 
supposed  prior  to  the  establishment  of  the  Rontgen  ray  as  a  diag- 
nostic measure. 


Fig.   416. 


Figs.  415  and  416. — Old  Colles'  fracture  showing  un-united  fracture  of  ulnar 
styloid  and  an  abnormal  condition  in  the  scaiJhoid.  Either  an  old  fracture  or  a 
"divided  scaphoid." 


A  study  of  tlie  X-ray  records  of  these  injuries  lias  brought  up 
a  most  important  and  confusing  subject ;  namely,  the  anomalies 
of  the  carpal  bones.  The  development  of  the  eari)us  shows  con- 
siderable variation  and  anomalies  of  the  bones  of  the  carpus  are 
comparatively  of  frequent  occurrence.  It  will  be  impracticable, 
here,  to  enter  into  all  the  possible  variations ;  the  reader  is  referred 
to  the  most  excellent  and  thorough  work  done  by  Thomas  Dwight, 
as  set  forth  in  his  book  on  "Variations  of  the  Bones  of  the  Hand 
and  Foot."  Occasion  will  be  taken,  however,  to  call  attention  to 
some  of  the   more  common  anomalies  which   are,   at  times,   con- 


INJURIES   TO    THE    CARPUS 


283 


founded  with  fracture.  Anomalies  may  consist  of  supernumerary- 
bones,  due  either  to  the  persistence  of  embryonic  elements  or  to 
the  division  of  one  or  more  of  the  carpal  bones.  Another  form  of 
anomaly  is  seen  in  instances  in  which  two  or  more  of  the  carpal 
bones  are  fused,  or  in  which  fusion  has  taken  place  between  an 
accessory  bone  and  one  of  the  bones  of  the  carpus.  These  anoma- 
lies of  fusion  are  of  anatomic  interest  onJy,  since  there  is  no 
occasion  for  mistaking  them  for  fractures  as  is  the  case  when  super- 


417. —  "Divided,  scaphoid." 


numerary  bones  are  present  or  when  one  of  the  bones  of  the  carpus 
is  divided. 

The  following  anomalies  are  described  in  detail  by  Dwight,  and 
from  a  surgical  standpoint  are  the  most  important  occurring  in 
the  carpus. 

The  scaphoid  is  not  uncommonly  divided,  either  partiall^^  or  com- 
pletely, into  two  lateral  portions.  An  example  of  this  condition 
is  shown  in  Fig.  417.  This  anomaly  resembles  fracture  of  the 
scaphoid. 


284 


FRACTURES   AND   DISLOCATIONS 


Fig.    418. — C'entrale   iireseiit   ami   fused   witli   os   magnum. 


Fig.    419. — Fractured    trapezium    indicated    by    upper    arrow.      CoUes'    fracture    in- 
dicated by  lower   arrow. 


INJURIES   TO    THE    CARPUS  285 

The  semihmar  sometimes  gives  the  appearance  of  being  divided 
into  a  palmar  and  a  dorsal  portion,  but  this  is  probably  due  to  an 
accessory  bone  to  be  spoken  of  later  (the  epihmatum). 

The  cuneiform  varies  considerably  in  both  size  and  form  but  sel- 
dom presents  any  anomaly  which  might  be  mistaken  for  fracture. 

The  pisiform  may  show  some  variations  in  size  and  shape ;  there 
may  be  an  accessory  pisiform. 

The  hamular  process  of  the  unciform  may  be  separate  from  the 
body  of  the  bone  and  the  line  of  division  may  be  mistaken  for  a 
fracture. 

The  epiluiiatum  and  Jiypolunatum  are  -two  accessory  bones  which 
(when  present)  are  situated  at  the  tips  of  the  crescentic-shaped 
semilunar.  The  dorsal  anomaly  (the  epilunatum)  is  more  fre- 
quent and  usually  of  larger  size  than  the  hypolunatum  which 
occurs  opposite  the  ventral  horn  of  the  semilunar.  The  epilunatum 
is  sometimes  well  developed  while  the  semilunar  is  correspondingly 
smaller  than  usual.  This  condition  gives  the  appearance  of  a  di- 
vided semilunar  and  may  be  mistaken  for  fracture. 

The  styloid  process  of  the  middle  metacarpal  is  sometimes  free 
and  appears  as  a  supernumerary  bone  in  the  carpus. 

The  centrale  is  a  supernumerary  ossicle  sometimes  seen  between 
the  OS  magnum,  scaphoid  and  trapezoid.  An  example  of  this  con- 
dition is  shown  in  Fig.  407.  Fig.  408  shows  the  same  condition 
except  that  the  anomalous  structure  has  never  ossified,  though  the 
space  for  its  accommodation  persists. 

Fig.  405  shows  an  example  of  the  triangulare  which  may  be  mis- 
taken for  a  fractured  ulnar  styloid. 

The  radiale  externum  is  an  accessory  bone  situated  on  the  radial 
side  of  the  scaphoid  and  is  said  to  be  the  separated  tubercle  of  the 
scaphoid. 

The  ulnare  externum  is  an  accessory  ossicle  on  the  ulnar  side  of 
the  carpus  internal  to  the  cuneiform. 

The  suhcapitatum  is  an  accessory  ossicle  situated  at  the  base  of 
the  OS  magnum.  It  is  said  to  represent  the  detached  base  of  this 
bone. 

.  Numerous  variations  may  occur  in  the  carpus  which  have  not 
been  mentioned  but  those  cited  above  are  the  ones  most  likely  to 
be  confused  with  fractures  in  this  region.  The  recognition  of  these 
anomalies  and  their  differentiation  from  fractures  of  the  carpus 
will  be  considered  later  under  Diagnosis. 


286  FRACTURES   AND    DISLOCATIONS 

The  bones  of  tlio  wrist  begin  to  ossify  in  the  following;  order: 
the  OS  niagniun  and  Ihe  nneiforni  during  th(>  tirst  year,  the  cunei- 
form during  the  third  year,  the  semilunai-  and  trapezium  durinoj 
the  fifth  year,  the  seaphoid  during  the  sixth  and  the  trapezoid 
during  the  eighth  year.  The  ]iisiform  begins  to  ossify  anywhere 
from  the  eighth  to  the  twelfth  year. 

The  scaphoid  is  oeeasionally  broken  as  a  result  of  forces  similar 
to  those  producing  Colles'  fracture.  The  line  of  fracture  is  usu- 
ally across  the  middle  of  the  bone  as  shown  in  Fig.  411.  This 
fracture  is  not  an  uncommon  complication  of  fractures  of  the 
lower  end  of  the  radius.  A  fragment  of  the  scaphoid  may  be  dis- 
placed or  luxation  of  the  entire  bone  may  accompany  fracture  of 
the  lower  end  of  the  radius  or  some  of  the  other  bones  of  the 
carpus.  The  few  reported  cases  of  uncomplicated  luxation  of  the 
scaphoid  have  been  of  the  backward  type  and  were  probably  due 
to  forced  flexion  of  the  wrist.  Forward  luxations  seem  to  be  in- 
variably complicated  by  some  other  lesion,  such  as  fracture  of  the 
lower  end  of  the  radius. 

The  semilunar  is  rarely  fractured  as  an  isolated  injury.  Luxa- 
tion of  this  bone,  however,  is  not  uncommon  and  may  be  accom- 
panied by  fracture  of  the  scaphoid  or  other  lesions  in  the  adjoining 
carpal  bones  or  in  the  radius.  The  displacement  in  luxations  is 
almost  invariably  forward,  the  bone  apparently  being  driven  from 
its  position  among  the  other  carpal  bones  by  forced  dorsal  flexion 
of  the  wrist. 

The  cuneiform  is  rarely  injured  except  in  general  crushes  of  the 
carpus. 

The  uncifornh  is  rarely  injured  except  as  the  result  of  direct 
violence,  though  a  few  cases  of  isolated  luxation  have  been  reported. 

Both  fracture  and  luxation  are  occasionally  seen  in  the  os  mag- 
num though  the  latter  condition  is  almost  always  partial,  or  more 
properly  a  subluxation.  The  displacement  is  backward  and  the 
result  of  forced  flexion  of  the  wrist.  Chronic  subluxations  of  the 
head  of  the  os  magnum  may  result  from  heavy  manual  labor,  espe- 
cially in  children. 

Both  fractures  and  luxations  of  the  trapezium  and  trapezoid  are 
exceptionally  rare  as  isolated  injuries. 

The  pisiform,  is  known  to  have  been  broken  through  the  action  of 
the  attached  flexor  carpi  ulnaris  and  luxation  of  this  bone  has  been 
reported  a  number  of  times.     The  pisiform  is  sometimes  broken  as 


INJURIES   TO    THE    CARPUS 


287 


a  result  of  direct  violence.  The  position  of  this  hone  is  more  ex- 
posed than  other  bones  of  the  carpus.  The  displacing  action  of 
the  flexor  carpi  ulnaris  may  separate  the  fragments.  Rupture  of 
the  piso-raetacarpal  and  piso-nncinate  (tlie  equivalents  of  the  ten- 
don below  the  bone)  may  resvilt  in  an  upward  luxation  of  the 
pisiform. 

In  crushing  injuries  of  the  carpus  any  or  all  of  the  bones  ma}' 
be  injured,  depending  on  the  nature  and  severity  of  the  trauma. 

Symptoms. — The  symptoms  accompanying  fractures  and  luxa- 
tions of  the  carpus  depend  on  the  nature  of  the  injury  and  the 
position  of  the  resultant  lesion  or  lesions. 

Ill  dislocations  of  the  wrist  (radio-carpal  joint)  the  carpus  is 
usually  displaced  backward.     The  deformity  is  low  and  al^ruj)!  in 


Fig.  420. — Severe  compound  fracture  dislocation  of  wrist  sustained  in  railroad 
accident.  Skin  is  the  only  tissue  connecting  forearm  and  hand.  Rubber  tournic[uet 
seen  in  position  having  been  applied  to  control  hemorrhage  immediately  following  acci- 
dent.     Picture  taken  just  prior  to  amputating. 


outline  and  the  extensor  tendons  stand  out  prominently  as  they 
pass  from  the  dorsum  of  the  forearm  to  the  back  of  the  hand. 
The  clinical  appearance  of  this  deformity  is  well  shown  in  Fig. 
379.  Palpation  of  the  lower  end  of  the  radius  will  show  that  this 
bone  is  intact  if  the  condition  is  a  pure  luxation.  Pain  and  loss 
of  function  accompany  the  injury  and  are  pronounced.     Swelling 


288  FRACTURES   AND   DISLOCATIONS 

develops  rapidly  and  if  the  case  is  not  seen  soon  after  the  accident 
the  deformity  is  to  some  extent  obscured.  Tf  this  luxation  is  com- 
plicated by  fractui-e  of  the  lower  end  of  thf  radius  crepitus  will 
be  present  and"  there  is  likely  to  be  a  tendency  to  recurrence  of 
deformity  foUowinu'  redm-tion.  In  the  anterior  form  of  luxation 
the  deformity  is  of  the  gardener 's-spade  type  and  resembles  the 
displacement  seen  in  reversed  Colles'  fracture.  The  deformity, 
however,  is  lower  and  more  abrupt  in  outline  and  the  posterior  lip 
of  the  lower  end  of  the  radius  stands  out  ])i'otiiineiitly.  Since  this 
luxation  is  fre(|uently  complicated  by  fracture  of  the  lower  end  of 
the  radius  crepitus  nuiy  be  present. 

The  symptoms  accompanying  ni'dio-carixiJ  luxations  closely  re- 
senil)h'  those  of  dislocation  of  the  radio-carpal   articulation.     The 


Fig.  421. — Slight  dpformitv  following  compound  crushing  injury  of  the  lower  end 
of  ulna  and  radius  and  the  xilnar  side  of  carpus.  Wrist  was  caught  in  large  gears. 
Picture  taken  some  years  after  recovery. 

deformity,  how^ever,  is  slightly  lower  and  it  may  be  possible  to  pal- 
pate the  proximal  row  of  carpal  bones  in  their  normal  relations 
with  the  radius.  Since  this  luxation  is  practically  alw'ays  compli- 
cated by  fracture  of  the  carpal  bones  or  of  the  lower  end  of  the 
radius  crepitus  is  to  be  expected.  The  luxation  may  be  either  for- 
ward or  backward  and  accordingly  the  deformity  may  be  either  of 
the  silver- fork  or  gardener 's-spade  variety. 

The  symptoms  accompanying  isolated  fractures  and  luxations  of 
the  carpal  bones  are  indistinct  and  not  characteristic  as  compared 
with  other  lesions  in  this  region.  This  will  be  found  particularly 
true  in  cases  in  which  swelling  is  pronounced.  The  following  symp- 
toms, however,  are  more  or  less  peculiar  to  lesions  of  the  different 
bones. 


INJURIES   TO    TflE    CARPUS  289 

Fracture  of  the  scaphoid  is  usually  accompanied  by  local  tender- 
ness in  the  "anatomical  snuff  box."  The  hand  may  be  slightly  ab- 
ducted and  the  vertical  depth  of  the  radial  side  of  the  carpus  may 
be  somewhat  diminished  if  the  scaphoid  has  been  crushed  or  com- 
pletely luxated.  It  may  be  possible  to  elicit  crepitus  and  in  some 
cases  it  may  be  accurately  enough  located  to  be  recognized  as  ema- 
nating from  the  scaphoid.  Isolated  luxation  of  the  scaphoid  is  a 
rare  condition  and  the  symptoms  vary,  according  to  the  direction 
of  the  dislocation,  whether  or  not  the  scaphoid  is  fractured  as  well 
as  luxated  and  the  completeness  of  the  displacement.  Palpation 
at  the  back  of  the  wrist  may  reveal  the  absence  of  the  scaphoid 
from  its  normal  position  if  the  luxation  is  ventral,  or  on  the  other 
hand,  there  may  be  an  abnormal  prominence  on  the  dorsal  aspect 
of  the  carpus  if  the  luxation  is  backward.  Crepitus  may  be  pres- 
ent if  fracture  complicates  the  luxation. 

The  symptoms  accompanying  fracture  of  the  semilunar  are  simi- 
lar to  those  of  fracture  of  the  scaphoid.  Fracture  of  the  semi- 
lunar, however,  rarely  occurs  as  an  isolated  injury,  and  when 
crepitus  is  detected  in  this  region  of  the  carpus  it  is  fair  to  pre- 
sume that  the  lesion  is  situated  in  the  scaphoid  rather  than  in  the 
semilunar.  In  forward  luxations  of  the  semilunar  the  displaced 
bone  may  be  palpated  on  the  ventral  aspect  of  the  wrist.  In  back- 
ward luxations  it  may  be  recognized  as  a  hard  prominence  just 
below  the  radius  and  at  about  the  middle  of  the  carpus. 

Fracture  of  the  cuneiform  is  practically  unknown  except  as  a 
part  of  extensive  injuries  in  which  the  carpus  is  crushed.  The 
author  knows  of  no  case  of  isolated  luxation  of  this  bone.  The 
symptoms  to  be  expected,  however,  would  resemble  those  accom- 
panying fracture  and  luxation  of  the  scaphoid  and  semilunar. 

Fracture  of  the  pisiform  is  not  necessarily  accompanied  by  char- 
acteristic symptoms  even  though  the  bone  is  more  superficial  than 
other  bones  of  the  carpus.  The  displacing  action  of  the  attached 
muscle  may  so  separate  the  fragments  that  crepitus  cannot  be  ob- 
tained. Pain  on  use  of  the  wrist  and  local  tenderness  may  be  the 
only  symptoms.  In  upward  luxations  of  this  bone  it  may  be  pos- 
sible to  recognize  the  altered  position. 

Fracture  of  the  os  magnum  is  accompanied  by  pain  and  tender- 
ness in  the  center  of  the  carpus,  more  or  less  loss  of  function  and 
crepitus  when  the  carpus  is  properly  manipulated  and  palpated. 
The  condition,   however,   is  rare   and  easily   confused  with    other 


290  FRACTURES   AND    DISLOCATIONS 

fractures  in  this  region.  Luxation  of  tliis  bone  is  quite  rare.  A 
number  of  eases  of  subluxation  of  the  liead  of  the  os  ma«;nuin  liave 
been  reported.  They  have  been  aeeompanied  by  an  luidnc  jironii- 
iience  on  the  doi-sal  aspect  of  the  carpus,  especially  during  com- 
plete dorsal  flexion  of  the  wrist.  The  loss  of  function  produced 
by  these  subluxations  is  siii'|irisiiii:ly  sliuhl.  v: 

Fnicturcs  of  the  Irapeziiim  anil  traixzuid  are  extremely  rare 
except  in  severe  crushes  of  this  region.  They  may  occur,  however, 
and  are  accompanied  by  crepitus  and  mobility  at  the  base  of  the 
first  or  second  metacarpal,  as  the  case  may  be.  Crepitus  in  the 
region  of  the  base  of  the  first  metacarpal  is  almost  always  caused 
by  Bennett's  fracture  and  rarely  by  fracture  of  the  trapezium  (see 
"Fractures  of  the  jMetacai-pals,"  page  297) .  Luxations  of  cither  of 
these  bones  is  extremely  rare,  and  since  only  dorsal  luxations  have 
been  reported,  the  prominence  of  the  displaced  bone  may  be  ex- 
pected on  the  dorsal  aspect  of  the  carpus. 

Fracture  of  the  tmciform  is  practically  unknown  except  as  a 
complication  of  luxation  or  in  severe  crushing  injuries  of  the 
carpus.  The  process  has  been  reported  as  broken  off  accompanying 
luxation. 

Diagnosis. — Theoretically  the  diagnosis  of  fractures  and  luxa- 
tions of  these  bones  should  be  easy  but  the  difficulty  of  ascertaining 
the  exact  nature  of  these  injuries  is  shown  by  the  frequency  with 
which  the  diagnosis  is  changed  after  the  X-ray  has  been  employed. 
The  appearance  of  the  wrist  is  so  characteristic  in  luxations  of  the 
radio-ulnar  joint  that  it  would,  seem  almost  impossible  to  fail  in 
recognizing  the  nature  of  the  injury.  It  is  a  well  known  fact, 
however,  that  Colles'  fracture  is  freciuently  mistaken  for  disloca- 
tion of  the  wrist.  One  who  has  never  seen  a  dislocated  wrist 
should  hesitate  in  pronouncing  an  injury  of  this  region  a  dislo- 
cation unles  the  diagnosis  has  been  confirmed  by  an  X-ray  ex- 
amination. (See  Figs.  378  and  379.)  Medio-carpal  luxations  are 
extremely  rare  and  it  wall  be  safer  to  make  only  a  tentative  diag- 
nosis pending  the  report  on  the  X-ray,  even  though  one  feel  reason- 
ably certain  of  the  condition. 

The  size  of  the  carpal  bones  and  their  compact  arrangement  are 
such  that  accurate  diagnoses  of  isolated  lesions  of  these  bones  are 
almost  impossible.  The  important  point  to  be  determined  by  in- 
spection and  palpation  is  w'hether  or  not  fracture  or  luxation 
exists.     The  treatment  of  the  different  traumatic  lesions  in  this 


INJURIES   TO    TriE    CARPUS  201 

region  is  similar,  and  the  details  of  the  damage  done  may  be 
learned  by  resorting  to  the  X-ray.  The  carpus  is  most  satisfac- 
torily palpated  by  flexing  the  wrist.  This  position  exposes  the 
dorsal  surfaces  of  the  carpal  bones  and  palpation  will  then  reveal 
any  abnormal  prominence  or  depression.  Slight  passive  motion 
while  palpating  the  carpus  in  this  way  will  usually  elicit  crepitus 
in  the  presence  of  fracture.  One  should  not  fail  to  use  the  oppo- 
site wrist  as  a  standard  of  comparison. 

In  the  interpretation  of  X-ray  plates  one  should  keep  in  raiud 
the  more  common  anomalies  as  mentioned  under  the  heading  of 
"Surgical  Anatomy,"  on  page  282.  The  Rontgenographic  recog- 
nition of  anomalous  bones  depends  on  the  position  and  structure 
of  the  supernumerary  ossicle  and  its  presence  in  the  opposite 
carpus.  The  X-ray  plate  should  show  the  structure  of  the  bones 
of  the  carpus  as  well  as  their  outlines.  It  should  be  remembered 
in  this  connection  that  the  structure  of  supernumerary  bones 
is  similar  to  that  of  the  normal  bones  of  the  carpus.  This  point 
is  of  importance  in  distinguishing  anomalous  bones  from  fractures. 
The  interior  of  each  bone  is  composed  of  cancellous  tissue  while 
the  surface  is  finished  oif  by  a  thin  layer  of  compact  bone.  A 
fractured  surface  will  be  more  or  less  uneven  and  the  trabeculae 
of  the  cancellous  tissue  will  open  onto  the  line  of  fracture.  The 
trabeculee  of  an  anomalous  bone  do  not  open  onto  any  surface  but 
are  covered  by  a  thin  layer  of  compact  tissue  which  shows  as  a 
thin  continuous  line  in  the  X-ray  plate.  Anomalous  bones  are  not 
necessarily  bilateral,  yet  if  an  osseous  anomaly  of  development  is 
found  in  one  side  of  the  skeleton  an  X-ray  of  the  same  region  on 
the  opposite  side  of  the  body  will  almost  invariably  show  a  cor- 
responding condition. 

Treatment. — Reduction  of  luxations  of  either  the  radio-carpal  or 
medio-carpal  joints  is  accomplished  by  traction  and  counter-trac- 
tion with  direct  pressure  over  the  prominent  displaced  carpus. 
It  is  seldom  that  difficulty  is  experienced  in  correcting  the  dis- 
placement. There  is  rarely  any  tendency  to  recurrence  of 
deformity  in  uncomplicated  cases.  Fracture  luxation  of  the  wrist 
may  tend  to  recur  if  the  radial  fragment  is  large.  Following 
reduction  the  wrist  should  be  immobilized  on  a  short  ventral  splint. 
The  further  conduct  of  the  case  will  be  considered  under  ''After- 
treatment,"  page  292.  Displacement  is  seldom  pronounced  in 
fractures  of  the  carpal  bones  and  when  reduction  is  necessarv  it 


292  FRACTURES   AND   DISLOCATIONS 

will  usually  oonsist  of  forcino;  prominont  fracfments  back  into  posi- 
tion. Kecluctioii  of  luxations  of  the  mi-pal  bones  may  bi'  readily 
accomplished  iu  some  cases  by  direct  pressure,  while  in  other  in- 
stances it  may  be  impossible  without  operative  intervention.  In 
dorsal  luxation  of  any  bone  of  the  carpus  tlie  wrist  sliould  ))e 
t\('Ki'd  until  the  displaced  bone  is  "started"  hack  into  llic  position 
which  it  previously  oeeui)ied.  When  the  bone  is  once  "started" 
the  hand  should  be  extended  until  it  comes  in  line  with  the  fore- 
arm, when  traction  and  countertraction  are  exerted  and  the  carpal 
bone  driven  home  l)y  direct  pressure.  In  the  reduction  of  ventral 
luxations  the  opposite  manipulation  is  followed.  The  wrist  is 
fully  extended,  the  dislocated  bone  started  back  into  position,  the 
hand  then  brought  to  a  straiiiht  line  witli  the  forearm  and  reduction 
eomi)leted.  Following  any  fracture  or  luxation  of  the  carpus  im- 
mobilization is  indicated. 

Operative  Treatment. — Operation  is  indicated  in  compound 
cases  and  in  instances  in  Avhich  reduction  cannot  be  effected  by 
manipulation.  Closed  luxations  at  the  wrist  seldom  call  for  op- 
erative measures.  Recurrence  of  deformity  in  fracture-luxations 
of  the  radio-carpal  joint  may  require  fixation  of  the  radial  frag- 
ment. Displaced  fragments  of  carpal  bones  or  a  completely  lux- 
ated bone  may  require  removal  through  incision.  Old  fractures 
or  luxations  of  the  carpal  bones  with  restriction  of  motion  due  to 
mechanical  interference  from  a  luxated  bone  or  displaced  frag- 
ment, may  require  operation  with  removal  of  the  obstructing  bone 
or  fragment. 

After-Treatment. — Fixation  of  the  wrist  following  fractures  and 
luxations  of  the  carpus  is  essential,  yet  early  passive  motion  is 
equally  necessary  if  the  function  of  the  part  is  to  be  fully  restored. 
It  is  apparent  that  non-union  of  any  one  of  the  carpal  bones 
would  not  offer  any  mechanical  obstacle  to  the  full  restoration  of 
function.  Yet,  on  the  other  hand,  it  is  a  noteworthy  fact  that 
cases  which  are  allowed  free  use  of  the  wi-ist  following  the  acci- 
dent do  not  show  the  complete  and  rapid  recovery  seen  in  cases 
treated  by  proper  immobilization  and  passive  motion.  Early  unre- 
stricted use  of  the  wrist  is  followed  by  a  chronic  inflammation  of 
the  synovial  surfaces  which  results  in  stiffening  of  the  wrist.  Pro- 
longed immobilization  without  passive  inotion  is  followed  by  joint 
adhesions  which  are  equally  detrimental  to  function.  The  proper 
treatment  consists  in  immobilization  of  the  parts  with  early  passive 


INJURIES   TO    THE    CARPUS  293 

motion.  Passive  motion  should  be  begun  as  soon  as  the  tranmatic 
reaction  has  subsided  and  shouhl  be  repeated  at  intervals  of  three 
or  four  days  until  the  splint  is  removed.  At  the  end  of  three 
or  four  weeks  all  dressings  may  be  dispensed  with  and  the  patient 
instructed  to  gradually  increase  the  use  of  the  wrist.  Massage  and 
hot  applications  are  of  value  in  hastening  the  restoration  of  func- 
tion. 

Prognosis. — Uncomplicated  fractures  and  luxations  of  the 
carpus  in  young  or  middle  aged  persons  are  followed  in  most  in- 
stances by  at  least  a  fair  restoration  of  function.  In  elderly  per- 
sons the  wrist  is  likely  to  remain  painful  and  to  show  more  or  less 
restriction  of  motion  in  spite  of  the  most  painstaking  treatment. 
Compound  fractures  of  the  carpus,  especially  crushes,  have  a  much 
more  unfavorable  prognosis.  If  infection  follows  in  compound 
cases  the  chances  of  a  stiff  wrist  are  great,  to  say  nothing  of  the  pos- 
sible loss  of  function  in  the  fingers  due  to  adhesions  between  the 
tendons  and  their  sheaths.  When  function  is  restricted  or  pain- 
ful as  a  result  of  the  displacement  of  one  of  the  carpal  bones,  the 
outlook  is  good,  if  the  condition  is  corrected  by  operative  meas- 
ures. 


CHAPTER  XXT. 

LUXATIONS  OF  THE  CARPOMETACARPAL 
ARTICULATION. 

Surgical  Anatomy. — The  articulation  between  the  carpus  and 
nietaeaipal  bones  is  heavy  and  strong,  and  complete  luxations  of 
tliis  .joint  are  extremely  rare.  From  a  surgical  standpoint  the  articu- 
lation may  be  divided  into  two  parts :  first,  the  articulation  between 
the  inner  four  metacarpals  and  the  carpus,  and  second,  the  joint 
between  the  trapezium  and  first  metacarpal.  Tlie  articulations 
between  the  inner  four  metacarpals  and  the  carpus  are  functionally 
one  continuous  joint.  The  synovial  cavity  extends  from  the  second 
to  the  fifth  joint  and  is  not  subdivided  by  the  ligaments.  The 
three  inner  carpal  bones  articulate  with  each  other  above  the  plane 
of  this  joint  and  the  metacarpals  below  the  joint  articulate  with 
each  other  by  their  lateral  surfaces.  The  inner  four  metacarpal 
joints  are  arthrodial  in  type ;  the  fifth  joint  is  capable  of  a  wider 
range  of  motion  than  the  other  three.  The  carpo-metacarpal  joint 
of  the  thumb  is  one  of  reciprocal  reception  (saddle  joint)  and  per- 
mits of  motion  in  all  directions  except  axial  rotation.  The  articu- 
lation between  the  first  metacarpal  and  the  trapezium  is  sur- 
rounded by  a  capsule,  is  separated  from  the  other  carpo-metacarpal 
articulations  and  has  its  own  synovial  membrane.  All  five  carpo- 
metacarpal articulations  are  known  to  have  been  luxated,  and  all 
except  that  of  the  little  finger  have  been  reported  as  isolated  in- 
juries. Dislocation  may  occur  in  one  or  more  of  the  joints  simul- 
taneously, and  a  number  of  instances  of  luxation  of  all  five  articu- 
lations have  been  recorded.  Luxation  may  occur  in  any  direction 
l)ut  the  most  common  forms  are  either  forward  or  backward.  The 
lateral  support  which  the  inner  four  metacarpals  offer  each  other 
explains  the  rarity  of  lateral  luxations.  The  carpo-metacarpal 
joint  of  the  thuml)  is  the  most  commonly  luxated.  ]\lore  disloca- 
tions of  this  joint  have  been  reported  than  of  the  other  four  carpo- 
metacarpal articulations  combined.  Backward  luxations  of  the 
carpo-metacarpal  joint  of  the  thumb  are  by  far  the  most  common. 

294 


LTTXATTONS    ()('■'    CAUI'O-M  KTACAKl'AT;    A  RTKU  !I;ATI()N  205 

Forward  luxations  are  oxtrcnicly  rare.  Ijiixalions  of  lliis  Joint 
are  not  infrecjuently  eoyn|)li('ate(l  l)y  fracture  of  either  tin;  trape- 
zium or  base  of  the  lirst  metacarpal  or  by  luxation  of  the  adjoining 
carpo-metacarpal  joint  of  the  index  finger.  Ijuxation  of  the  carpo- 
metacarpal joint  of  the  index  finger  is  next  in  order  of  frequency 
and  is  more  often  displaced  backward  than  forward.  Luxations 
of  the  third,  fourth  and  fifth  carpo-metacarpal  articulations  are 
extremely  rare.  They  may  be  either  of  the  forward  or  backward 
type.  Subluxations,  especially  of  the  backward  type,  are  not  as 
rare  in  the  four  inner  metacarpals  as  in  complete  luxation.  Di- 
vergent luxations  have  been  reported  in  which  some  of  the  meta- 
carpal bases  have  been  displaced  backward  while  others  were 
luxated  anteriorly.  This  form  of  dislocation,  howevei",  is  extremely 
rare  and  can  hardly  be  considered  as  a  type.  Severe  crushing  vio- 
lence in  this  region  may  produce  almost  any  type  of  fracture- 
luxation  as  in  the  carpus,  and  because  of  the  superficial  position 
of  the  bones  is  likely  to  be  compound. 

Symptoms. — In  luxations  of  the  carpo-metacarpal  joint  of  the 
thumb  there  will  be  loss  of  function,  shortening  of  the  thumb  and 
"Characteristic  deformity.  In  the  backward  type  the  base  of  the 
first  metacarpal  will  be  unduly  prominent  on  the  dorsal  aspect  of 
the  carpus,  just  below  the  end  of  the  radius.  In  the  ventral  type 
the  trapezium  may  be  palpated  and  the  base  of  the  metacarpal 
forms  a  hard  prominence  beneath  the  thenar  eminence.  Various 
degrees  of  angular  deformity  may  be  present  as  well  as  the  over- 
riding displacement.  The  forward  or  backward  displacement  ac- 
companying luxations  of  any  or  all  of  the  inner  four  articulations 
can  be  appreciated  without  difficulty  if  the  case  is  seen  early.  If 
the  injury  is  not  examined  before  the  onset  of  the  traumatic  reac- 
tion the  swelling  may  be  so  pronounced  that  the  nature  of  the 
deformity  is  not  apparent.  The  shortening  of  the  fingers,  however, 
will  be  a  symptom  which  will  be  evident  even  though  the  balance 
of  the  deformity  is  obscured  by  swelling. 

Diagnosis. — Luxation  of  any  one  of  these  joints  should  be  recog- 
nized without  difficulty  if  the  case  is  seen  early.  When  four  or 
five  of  the  metacarpals  are  dislocated  simultaneouslj^  the  traumatic 
reaction  may  be  so  severe  that  diagnosis  is  rendered  difficult  unless 
the  patient  is  anesthetized  or  the  X-ray  resorted  to.  Fracture  of 
either  the  carpals  or  metacarpals  is  not  an  uncommon  complication 
and  is  recognized  by  the  presence  of  crepitus.     If  doubt  exists  the 


296  FRACTURES   AND   DISLOCATIONS 

X-ray  should  be  employed.  In  interpreting  X-rays  of  this  region 
the  anomalies  mentioned  under  the  Surgical  Anatomy  ol;  "Injuries 
to  the  Carpus"  on  page  283,  should  be  kept  in  mind. 

Treatment. — Reduction  is  usually  accomplished  without  diffi- 
culty by  traction,  counter-traction  and  direct  pressure  on  the  dis- 
placed metacarpal  base  or  bases.  Luxation  of  the  earpo-metacarpal 
of  the  thumb  is  more  likely  to  give  trouble  in  reduction  than  are 
the  corresponding  joints  of  the  other  fingers.  If  reduction  can- 
not be  effected  by  manipulation  open  reduction  may  be  necessary. 
A  tendency  to  the  recurrence  of  deformity  seldom  occurs  in  any  of 
these  joints  unless  fracture  complicates  the  luxation.  Following 
reduction  the  wrist  and  hand  (but  not  the  fingers)  should  be  im- 
mobilized on  a  short  splint.  The  character  of  the  splint  is  not 
essential  as  long  as  it  fits  the  parts  comfortal)ly  and  effects  immo- 
bilization. 

Operative  Treatment. — Operation  is  seldom  indicated  in  the 
reduction  of  luxations  of  single  joints.  In  luxations  which  can- 
not be  reduced  by  manipulation  the  articulation  should  be  exposed 
by  a  longitudinal  incision  and  the  displacement  corrected  by  direct 
manipulation  through  the  incision.  Compound  cases  should  be 
treated  as  described  under  "Treatment  of  Compound  Fractures  and 
Luxations"  on  page  789. 

After-Treatment. — The  after-care  of  these  cases  is  practically  the 
same  as  that  already  given  under  "Injuries  to  the  Carpus"  (page 
292).     Early  passive  motion  is  most  important. 

Prognosis. — The  outlook  in  luxations  of  the  carpo-metacarpal 
articulations  is  similar  to  that  already  given  under  "Injuries  to 
the  Carpus. ' '  Loss  of  function  in  the  first  carpo-metacarpal  articu- 
lation will  lead  to  difficulty  in  opposing  the  thumb  against  the 
fingers,  and  will  constitute  a  serious  handicap  in  the  use  of  the 
hand.  In  compound  cases  the  prognosis  is  much  more  unfavorable, 
especially  in  the  presence  of  infection. 


CHAPTER  XXII. 

FRACTURES  OF  THE  METACARPALS. 

Surg-ical  Anatomy. — The  structure  of  the  metacarpals  resembles 
that  of  other  long  bones  with  the  exception  of  the  ossification. 
The  ossification  of  the  inner  four  bones  is  the  same.  One  center 
for  the  shaft  and  base,  and  one  for  the  distal  end  or  head.  The 
center  for  the  single  epiphysis  is  first  seen  about  the  third  year 


Fig.  422. — Fracture  of  the  base  of  the  first  metacarpal  entering  the  joint.      Bennett's 
fracture. 

and  joins  the  shaft  during  the  twentieth.  The  metacarpal  of  the 
thumb  has  its  single  epiphysis  located  at  the  base.  It  begins  to 
ossify  during  the  third  year  and  joins  the  shaft  in  the  twentieth. 
Occasionally  this  bone  has  an  additional  epiphysis  for  the  head 

297 


298 


FRACTURES  AND  IHSLOOATK  )NS 


wliicli  is  visihlf  ;i1  the  scvnitli  or  ei<ihth  year.  The  first  metacarpal 
iiuiy  tliiis  rcsciiihic  Itolh  plwiliiiix  and  luotaearpal  in  its  process  of 
ossiticatioii.  T1,U'  i)ositioiis  of  tlic  epiphyseal  eartihiges  are  of  im- 
portance ill  iiiterpretiiiu-  lu'iiit^eiioizfaiiis  of  this  region.  The  shaft 
of  a  metacarpal  is  composed  of  a  tul)e  of  compact  tissue,  while  the 
extremities  are  cancellated  and  enclosed  in  a  thin  layer  of  com- 
pact hone.  This  change  in  structure  between  the  sliat'ts  and  ex- 
tremities accounts  for  the  not  unconunon  impaction  of  the  shaft  into 
the  head  of  the  hone  followinti'  a  blow  on  the  knuckle.     Fracture 


Fig.  423. — Gun-shot  friicture  of  liit'  tliird  inotacavpal.  This  plate  shows  tlie  epipliy- 
sis  of  the  hand  at  thirteen  years  of  age.  Note  the  single  epiphyses  of  the  phalanges 
situated  at  the  proximal  ends  of  the  bones.  The  epiphyses  of  the  metacarpals  are 
situated   at  the   distal   ends   of  the  bones  with  the   e.xception   of   the  first   metacarpal. 


of  the  metacarpal  shafts  usually  results  from  direct  violence,  while 
fracture  of  the  distal  end  is  almost  always  caused  by  indirect 
violence.  Fracture  of  the  distal  end  is  almost  invariably  produced 
in  boxing  or  fighting.  A  "punch"  is  "landed"  on  some  bony 
prominence  such  as  the  jaw  or  skull,  and  the  head  of  the  most 
prominent  metacarpal  is  driven  upward  onto  the  shaft  of  the  bone 
and  also  displaced  slightly  into  the  palm  of  the  hand.  This  for- 
ward displacement  is  due  largely  to  the  normal  curvature  of  the 
shaft  and  to  the  fact  that  the  palmar  aspect  of  the  head  is  not  as 


FRACTURES    OF    TJIIO    METACARPATjS  299 

well  supported  as  the  dorsal.  When  the  hand  is  tightly  closed  in  a 
fist  the  heads  of  the  metacarpals  form  the  prominence  of  the 
metacarpo-phalangeal  knuckles  and  the  impact  of  violence  sustained 
on  these  knuckles  is  the  most  common  cause  of  fracture.  Frac- 
ture is  not  uncommon  in  any  of  the  metacarpals  but  is  most  fre- 
quently seen  in  the  third  and  fourth.  The  most  usual  site  of  frac- 
ture in  the  inner  four  bones  is  just  above  the  head  while  the  most 
common  seat  of  the  break  in  the  metacarpal  of  the  thumb  is  through 
the  base  and  involving  the  articular  surface.  Fracture  of  the  base 
of  the  first  metacarpal  is  known  as  Bennett's  fracture.  The  clin- 
ical appearance  and  X-ray  findings  inthis  lesion  are  well  shown 
in  Figs.  422  to  424.  The  first  metacarpal  is  isolated  and  can  be 
palpated  Avithout  difficulty,  while  the  posterior  surfaces  of  the 
inner  four  bones  are  subcutaneous  and  can  be  palpated  from  end 
to  end  unless  the  hand  is  markedly  swollen.  A  number  of  meta- 
carpals may  be  fractured  simultaneously  but  it  is  much  more 
common  to  see  an  isolated  fracture  of  one  of  them  a  short  distance 
above  the  head. 


Fig.    424. — Bennett's    fracture    in    the    right    hand.      Note    the    abnormal    pro.ninenca 
at  the  base  of  the  first  metacarpal.      Pictvire  taken  a   few  minutes  following  the   accident. 

Symptoms. — Pain,  swelling,  tenderness  and  loss  of  function  are 
constant.  The  disturbance  in  function  accompanying  fracture 
of  one  or  more  of  the  metacarpals  usually  consists  in  an  inability  to 
completely  flex  the  fingers.  This  is  due  to  pain,  swelling  and  the 
fact  that  the  head  of  the  fractured  metacarpal  is  displaced  so  that 
there  is  a  mechanical  interference  with  complete  flexion  of  the  first 
phalanx.  The  deformity  is  usually  characteristic  (see  Figs.  428 
to  433).  The  head  of  the  injured  bone  is  usually  displaced  into 
the  palm  and  when  the  fingers  are  flexed  the  corresponding  knuckle 
will  be  found  at  a  lower  level  than  normal.     It  will  often  be  pos- 


300 


FRACTURES  AND   DISLOCATIONS 


sil)lo  to  palpate  the  head  of  tlie  bone  in  the  palm  of  the  hand. 
AVhen  the  fraoture  is  at  or  near  the  middle  of  tlie  shaft  the  "drop- 
ping" of  the  knuckle  -svill  be  less  marked  while  the  backward  bow- 
ing of  the  shaft  will  be  pronounced.     Crepitus  can,  as  a  rule,  be 


y\g.  42'). — UeiiiU'tl's  fi'iu-ture  (biise  ul'  lirsl  niet;K-;irpal )  with  lateral  deforiuity. 
Note  the  prominence  indicated  by  arrow.  Deformity  producetl  by  lateral  displacement 
of  base  of  metacarpal. 


Fi_'.    JjT. — I'resHure    on    the    base    nf    the    metacarpal    effects    reduction. 

elicited  unless  the  fracture  is  near  the  distal  end  and  impacted. 

Diagnosis. — There  should  be  little  difficulty  in  recognizing  frac- 
ture of  any  of  the  metacarpals.  It  is,  however,  not  uncommon  to 
see  these  cases  mistaken  for  and  treated  as  a  "sprain."     There  is 


FRACTURES   OF    THE    METACARE'ALR  301 

no  excuse  for  this  mistake  if  the  parts  are  carefully  examined  fol- 
lowing the  injury.  The  deformity  is  usually  so  characteristic  and 
pronounced  that  the  diagnosis  can  be  made  hy  inspection  alone 
unless  the  swelling  is  exceptionally  pronounced.  Bennett's  frac- 
ture is  most  frequently  mistaken  for  a  sprain  or  subluxation  of  the 


Fig.  428. — FractTii'e  of  the  left  imlcx  nn'tacarpal  behind  the  head  of  the  bone  with 
dropping  of  the  knuckle.  Note  the  alignment  of  the  knuckles  of  both  hands  and  how 
the  index  knuckle  of  the  patient's  Jeft  hand  is  displaced  forward  toward  the  palm 
of  the  hand.  Condition  about  twelve  hours  old  and  the  result  of  "punching"  someone. 
Motion    and    crepitus   present    after    the    slight   impaction    is   broken   up. 


Fig.  429. — Fracture  of  right  index  metacarpal  of  about  four  years'  standing. 
Deformity  has  been  allowed  to  go  uncorrected,  knuckle  is  "dropped"  and  complete 
flexion  of  the  index  finger  impossible.  Prominence  of  metacarpal  head  may  be  felt  in 
the  palm.  The  fifth  metacarpal  of  the  same  hand  was  fractured  about  one  month  ago 
and  the  dressings  (similar  to  those  shown  in  Figs.  434,  435,  436  and  487)  have  just 
been  removed.  Note  how  the  knuckle  of  the  little  finger  is  up  in  line  with  the  other 
knuckles.  Swelling  has  not  yet  entirely  subsided  and  the  outline  of  this  knuckle  is  not 
as  sharp   as  the  same  knuckle  of   the  opposite  hand. 

articulation  between  the  first  metacarpal  and  trapezium.  INIanipu- 
lation  of  the  thumb  will  almost  invariably  elicit  crepitus  and  dis- 
close the  nature  of  the  injury  without  the  aid  of  the  X-ray. 

Treatment. — Reduction  of  the  usual  deformity  is  accomplished 
by  traction  on  the  finger  corresponding  to  the  injured  metacarpal. 
The  ligaments  connecting  the  base  of  the  first  phalanx  with  the 


302  FRACTURES   AND    1)1SU)CATK)XS 

liead  of  the  metacarinil  aro  tlius  cniployod  in  ])nllin<^'  \he  distal 
fragment  liaek  into  i)o.si1ioii.  During-  this  manipuhitioii  tlie  upper 
fragment  is  to  he  steadied   l)\    llic  tlimuh  and   fingers  of  the  op- 


Fig.   430. — Pronounced   "falling"    of   the  index  knuckle  due  to  fracture  of  the  second 
metacarpal   near   its  distal   end. 


Fig.   431.  Fig.    432. 

Figs.  431  and  432. — Two  views  of  a  iicent  fracture  of  the  fourth  metacarpal  near 
its  distal  end.  Note  the  slight  "falling"  (ventral  displacement)  of  the  fourth  knuckle. 
Photographs  taken  a  few  minutes  following  in.iury,  which  accounts  for  the  absence  of 
swelling. 

posite  liand.  Keduetion  is,  as  a  rule,  easily  aceomplislied  hut  the 
deformity  reeurs  as  soon  as  the  parts  are  released.  Tlie  dressings, 
therefore,  must  he  dei)ended  upon  to  retain  the  fragments  in  posi- 


PKACTtlKKS    OK    TIIR    METACy\RPALS  '308 

tion  during  the  process  of  repair.  It  will  usually  he  possihle  to  pre- 
vent overriding  displacement  hy  an  engagement  of  the  serrated 
fractured  surfaces,  hut  angular  deformity  can  only  he  avoided  by 
proper  dressings.  The  method  of  fixation  which  will  meet  the  re- 
quirements in  the  greatest  number  of  cases  is  shown  in  Pigs.  434 
to  437.  Following  reduction  a  roller  bandage  is  placed  in  the 
palm,  the  fingers  flexed  over  it  and  secured  in  position  hy  two 
strips  of  adhesive  plaster.  A  machine  rolled  bandage  such  as 
put  out  by  the  supply  houses  should  be  used  to  secure  the  proper 
firmness.     A  roller  four  inches  wide  by  ten  yards  in  length  is  most 


Fig.  433. — Fracture  of  fourth  metacarpal  about  twenty-five  years  ago  (during 
childhood).  Injury  to  the  epiphyseal  cartilage  with  subsequent  arrest  in  growth 
accounts,    in   part,    for   the   pronounced   deformity. 

appropriate.  The  diameter  of  this  roll,  however,  is  a  little  too 
great  for  the  average  size  hand  and  should  be  reduced  by  remov- 
ing the  outer  layers  of  the  bandage  until  it  is  small  enough  to 
allow  the  first  row  of  phalanges  to  be  flexed  to  a  right  angle  with 
the  metacarpals  as  shown  in  Fig.  434.  This  position  allows  the 
head  of  the  broken  bone  to  be  "raised"  into  line  with  the  other 
knuckles  without  making  upward  pressure  on  the  lower  fragment. 
After  the  roller  has  been  placed  in  position  diagonal  strips  of  ad- 
hesive are  used  as  shown  in  Fig.  436  to  raise  the  injured  knuckle. 
The  entire  hand  is  then  covered  with  a  bandage  and  carried  in  a 
sling. 

In  some  instances  the  fracture  is  situated  in  the  shaft  and 
oblique  enough  to  prevent  a  firm  engagement  of  the  broken  sur- 
faces. Under  such  circumstances  the  roller  bandage  will  not  cor- 
rect the  tendency  to  overriding  deformity-  and  continuous  traction 
will  be  necessary  to  keep  the  fragments  in  proper  relation.  A  nar- 
row splint  is  properlj^  padded  and  secured  to  the  palm  of  the  hand 


304 


FRACTURES   AND   DISLOCATIONS 


by  means  of  strips  of  adliosive  piaster.  This  splint  should  extend 
about  three  inches  be.yond  the  end  of  the  (•orri'si)ondiug  tinger. 
Extension  is  then  secured  by  means  of  light  rubber  tubiug;  one  end 
of  the  tulnuiT  is  "attai'hed  to  the  end  of  the  splint  wliih^  tlu^  other 


Fig.   434. — Roller    bandage    of    appropriate    si^e    placed    in    hand. 


F\s.     i:'.-"). — S;iiui,'    sirurrd    in    position    by 


Fig.   436. — Strips    of    adhesive    used    to    correct    deformity    and    raise    the    knuckle    of 
the  ring  finger. 


Fig.   437. — Hand   bandaged    and    dressing    complete. 


is  attached  to  the  tinger  by  means  of  strips  of  adhesive  plaster. 

Fractures  of  any  of  the  four  inner  metacarpals  may  be  treated 
by  means  of  two  splints  (dorsal  and  palmar)  properly  padded, 
though  they  are  not  as  reliable  and  secure  as  the  roller  bandage, 


FRACTURES  OF  THE  METACARPALS  305 

unless  made  of  plaster  of  Paris.  If  plaster  splints  are  used  they 
should  be  applied  with  due  regard  for  the  nature  and  tendency  of 
the  deformity.  Eight  or  ten  thicknesses  of  gauze  should  he  used 
and  the  material  cut  so  that  one  splint  will  cover  the  dorsal  aspect 
of  the  hand  and  wrist  while  the  other  covers  the  palm  and  ventral 
surface  of  the  wris.t.  These  two  splints  are  then  soaked  in  plaster 
cream,  wrung  out  and  rapidly  secured  in  position  by  a  roller  ban- 
dage. While  the  plaster  is  setting  the  surgeon  should  grasp  the 
hand  in  such  a  manner  that  pressure  will  be  made  in  the  palm 
opposite  the  displaced  head,  while  counter  pressure  is  exerted 
over  the  uninjured  metacarpals  on  the  dorsum  of  the  hand.  This 
raises  the  injured  knuckle  and  the  pressure  exerted  by  the  sur- 
geon's fingers  is  continued  by  the  splints  after  the  plaster  has 
set.  The  splints  should  be  removed  as  soon  as  the  plaster  has 
hardened  sufficiently  to  maintain  its  proper  form,  and  reapplied 
only  after  the  plaster  has  thoroughly  set  and  dried  out.  Placing 
the  splints  on  a  radiator  or  in  the  sun  will  hasten  the  process. 

Fracture  of  the  shaft  of  the  first  metacarpal  is  most  satisfactorily 
treated  by  means  of  the  splint  shown  in  Fig.  440.  The  curves 
of  the  thumb  and  thenar  eminence  are  such  that  an  accurately  fit- 
ting splint  can  be  had  only  by  using  a  material  such  as  plaster 
which  can  be  moulded.  Bennett's  fracture  often  requires  no  splint 
whatever.  It  is  frequently  possible  to  correct  the  lateral  and 
backward  displacement  of  the  base  of  the  bone  by  means  of  strips 
of  adhesive  plaster  exerting  pressure  in  the  direction  shown  in 
Fig.  427.  With  the  deformity  thus  corrected  the  thumb  is  im- 
mobilized with  adhesive  strapping  similar  to  that  employed  in 
the  treatment  of  a  sprain. 

Operative  Treatment. — Operation  is  almost  never  indicated  in 
recent  fractures  of  the  metacarpals  unless  the  condition  is  com- 
pound. When  the  fracture  is  open  it  should  be  treated  according 
to  the  principles  laid  down  under  "The  Treatment  of  Compound 
Fractures  and  Luxations"  on  page  789.  In  old  cases  with  de- 
formity the  patient  may  suffer  considerable  loss  of  function  with 
persistent  pain  or  tenderness  in  the  palm  opposite  the  displaced 
head.  If  these  symptoms  are  pronounced  and  intel'fere  with 
work  operation  is  indicated.  The  incision  is  best  made  on  the 
dorsal  aspect  of  the  hand  and  should  avoid  the  extensor  tendon 
of  the  corresponding  finger.  With  the  metacarpal  exposed  the 
bone  is  divided  at  the  original  site  of  fracture  and  the  knuckle 


306  FKACTL'RES    AND    DISLOCATIONS 

raisinl.  The  wound  is  tluMi  closed  and  tlio  condition  ticatcd  as  a 
recent    fracture   witli    the  deformity    fully   corrected. 

After-Treatment. Tlie  after-care  of  lliese  cases  calls  foi-  fre- 
quent inspection  of  the  dressinus  which  are  sure  to  become  lax  or 
slij)  no  matter  how  well  api)lied.  As  soon  as  the  di'cssinii-  becomes 
loose  the  deformity  recurs  and  th\is  a  (h'foi-med  \\;i]\<\  may  rolh)w 
even  though  the  original  i-eduction  was  perfect.  I'ressure  points 
may  show  erosion  during  the  after-treatment  and  call  for  treat- 
ment. If  the  roller  bandage  dressing  is  used  the  kiuiekles  under 
the  adhesive  stiai)s  may  become  ii'ritated  and  require  relief  from 
pressure.  With  the  slightest  signs  of  irritation  the  dressing  should 
be  reapplied  and  bits  of  cotton  placed  between  the  adhesive  plaster 
and  skin.  The  dorsum  of  the  hand  should  be  carefully  watched 
for  backward  bowing  of  the  shaft  of  the  fractured  metacarpal 
which  may  develop  at  any  time.  Direct  pressure  on  the  shaft 
may  be  necessary  and  is  had  by  means  of  pads  and  adhesive 
straps.  Backward  bowing  is  not  likely  to  occur  if  the  first 
phalanges  are  fixed  at  a  right  angle  wdth  the  metacarpals,  as 
previously  mentioned  under  "Treatment."  Immobilization  may 
be  discontinued  at  the  end  of  three  weeks  but  the  hand  should  not 
be  subjected  to  strain  for  another  two  weeks  as  deformity  may 
recur.     Heavy  work  should  be  avoided  for  two  months  or  more. 

Prognosis. — In  an  uncomplicated  fracture  of  one  of  the  meta- 
carpals w'ith  correction  of  the  deformity  there  should  be  complete 
restoration  of  function.  If  the  deformity  is  not  corrected  there 
will  be  incomplete  flexion  of  the  corresponding  finger,  a  weakened 
grip  and  more  or  less  pain  and  tenderness  in  the  palm  of  the 
hand  opposite  the  displaced  head.  These  symptoms  will  be  present 
according  to  the  degree  of  deformity. 


CHAPTER  XXIII. 

FRACTURES  OF  THE  FINGERS. 

Surgical  Anatomy. — The  phalanges  are  practically  subcutaneous 
throughout  and  fractures  of  these  bones  are,  as  a  rule,  detected 
without  difficulty.  The  fleshy  pads  on  the  palmar  aspect  of  the 
fingers  are  comparatively  thick,  and  palpation  on  this  side  of  the 
digit  is  less  satisfactory  than  elsewhere.  The  quadrilateral  ex- 
panded bases  may  be  palpated  without  difficulty.  The  internal 
structure  of  the  phalanges  is  similar  to  that  found  in  other  long 
bones.  The  extremities  are  composed  of  cancellous  tissue  covered 
by  a  thin  layer  of  compact  bone,  while  the  shafts  consist  of  tubes 
of  heavy  compact  tissue.  Accordingly  fractures  occurring  in  the 
extremities  are  more  prone  to  show  comminution  and  crushing  of 
cancellous  tissues,  while  breaks  through  the  shafts  are  usually 
clean  cut  and  never  impacted. 

The  dorsal  aspect  of  each  finger,  from  the  head  of  the  meta- 
carpal to  the  base  of  the  terminal  phalanx,  is  in  contact  with  the 
extensor  tendon.  The  anterior  aspect  of  each  digit  is  in  relation 
with  the  flexor  tendons.  The  tendons  of  the  flexor  sublimis  dig- 
itorum  are  inserted  into  the  sides  of  each  middle  phalanx,  while  the 
tendons  of  the  flexor  profundus  digitorum  are  inserted  into  the 
bases  of  the  terminal  phalanges.  These  tendons  and  the  synovial 
sheaths  enclosing  them  are  of  considerable  importance  in  the 
treatment  of  fractures  of  the  fingers.  Prolonged  immobilization, 
following  the  traumatic  inflammation  which  accompanies  fractures, 
is  likely  to  give  rise  to  adhesions  between  these  tendons  and  their 
sheaths;  such  adhesions  limit  motion  after  recovery  takes  place. 

Epiphyseal  separations  are  rare  in  the  fingers  though  they  are 
occasionally  seen.  Each  phalanx  is  ossified  by  two  centers,  one 
for  the  base  and  one  for  the  head  and  shaft.  The  bases  of  the 
proximal  row  of  phalanges  begin  to  ossify  during  the  third  or 
fourth  year  and  join  the  shafts  at  about  the  eighteenth  year. 
The  shafts  of  all  the  phalanges  show  signs  of  ossification  soon  after 
birth. 

307 


308 


FRACTURES   AND   DISLOCATIONS 


The  proraineiiees  of  the  knuckles  do  not  correspond  to  the  planes 
of  the  joint  but  are  formed  by  the  heads  of  the  bones  above  the 
articulation.  The  digital  vessels  and  nerves  run  on  either  side  of, 
and  a  little  ventral  to,  the  lateral  borders  of  the  phalanges. 

The  use  to  which  the  hands  are  put  in  the  diil'ereut  trades  and 
in  various  types  of  labor  exposes  the  fingers  to  all  kinds  of  direct 
violence.  This  is  particularl}'  true  of  those  working  about  ma- 
cliiiicry.  The  fact  that  the  phalanges  are  subcutaneous  results  in 
a    liigli    i)ropoi"tion   of    compound   fractures   and    luxations,    even 


Fig.   438. — Compound    frncture    of    the   base    of    the    terminal    phalan.x    of    the    middle 
finger  with  backward  displacement  and  tearing  of  nail  from  its  bed. 


Fig.  439. — Severe  compound  fractures  of  the  proximal  phalanges  of  the  fourth  and 
fifth  fingers.  Wounds  on  ventral  aspect  of  fingers.  Injury  sustained  in  machine  ac- 
cident. 


though  the  skin  covering  these  parts  is  heavy  and  strong.  Frac- 
tures of  the  fingers,  especially  those  produced  by  machinery,  are 
often  accompanied  by  severe  and  extensive  laceration  and  bruis- 
ing of  the  overljdng  soft  tissues. 

Symptoms. — Local  pain,  loss  of  function  and  swelling  of  the 
injured  finger  are  almost  invariably  present.  Crepitus  and  ab- 
normal mobility  can  usually  be  elicited  without  difficulty.  When 
the  fracture  is  near  the  end  of  the  phalanx  the  point  of  preter- 
natural mobility  may  be  difficult  to  recognize  because  of  the  prox- 


FRACTURES  OF  THE  FINGERS  309 

imity  of  the  joint.  Crepitus  is  not  as  easily  elicited  when  the 
break  is  near  the  end  of  the  bone.  Deformity  varies  considerably ; 
it  may  be  pronounced  enough  to  establish  the  nature  of  the  injury 
by  inspection  alone,  or  it  may  be  absent.  A  type  of  injury  known 
as  "base-ball  finger"  consists  of  fracture  of  the  terminal  phalanx 
with  impaction,  as  shown  by  the  X-ray,  but  the  symptoms  do  not 
conform  to  the  symptoms  accompanying  the  usual  fracture.     The 


Fig.   440.  Fig.   441. 


Fig.  440.- — Plaster  splint  applied  to  thumb.  The  curves  of  the  thumb  from  wrist  to 
thumb-tip  are  such  that  it  is  difficult  to  obtain  a  good  fit  with  any  other  form  of  splint. 

Fig.  441. — Plaster  splint  applied  to  dorsal  surface  of  middle  finger  and  back  of 
hand.      Secured  in  place  by  means  of  strips  of  adhesive. 

injury  is  produced  by  being  struck  on  the  end  of  the  finger  by  a 
base-ball.  Following  the  trauma  the  finger  is  painful  and  tender 
and  somewhat  swollen,  but  mobility  and  crepitus  are  usually  ab- 
sent. There  is  a  slight  deformity  which  can  not  be  recognized 
until  the  swelling  subsides.  These  fractures  are  often  overlooked 
if  the  case  is  not  examined  with  the  Rontgen  ray.  Recovery  is 
usually  slow,  the  finger  remaining  tender  and  painful  for  weeks 
and  even  months. 


810 


PRAOTtTRKS    ANP    DISLOCATIONS 


Diagnosis. — -Fractuifs  of  the  lingers  can  l)e  recognized  wilhont 
(lil'ficulty  if  till'  pni'ts  .-ire  (•jirct'iilly  cxniiiiiicd  following-  llic  injury. 
W'lirii  (Icroi'iiiity  is  in-csciit  llicic  iiiny  l»i'  ;i  tendency  lo  iceuiTeiiee 
of  displacement  rollowiiiL;'  rednetion  Imt  this  is  seldom  the  ease  in 
dislocations.  'I'lie  linui'i-  nail  I'endeivs  the  terminal  phalanx  diffienlt 
to  pali)ate,  and  the  typieal  hase-hall  I'l^ai-lnre  cannot  oi'dinai'ily 
be  recognized  in  this  \\a\.  The  X-i'ay  should  he  used  when  there 
is  doubt. 

Treatment. — The  ])i-oper  triatmeni  ol'  fi'aetnres  of  the  lingers  is 


Fig.   442. — Splint   of  cigiir-l.ox   wdiid   ii;i(ldcd,   ijinulagod   iiiid   placed   in  position   to   im- 
mobilize middle  finger.      Note  tlie  cotton   in  inilm  of  hand. 

of  greater  importance  than  would  at  first  appear  since  there  is 
only  a  small  proportion  of  men  who  do  not  depend,  at  least 
partially,  on  their  hands  for  a  livelihood.  A  crippled  hand  often 
Tiieans  impaired  earning  capacity. 

When  there  is  deformity  it  should  be  corrected  at  the  earliest 
possible  moment  and  the  finger  immobilized.  In  fractures  of  the 
phalanges  it  has  been  customary  to  immobilize  the  injured  finger 
in  a  position  of  complete  extension.  A  position  of  slight  flexion, 
however,  will  be   found   much   more  comfortable  since  the   flexor 


FRACTURES   OF    THE    FINGERS 


:ui 


and  extensor  tendons  more  nearly  balance  each  other  in  this  at- 
titude. A  straight  palmar  splint  may  be  used  as  shown  in  Fig. 
442,  but  the  padding  should  be  so  arranged  that  the  surface  coming 
in  contact  with  the  finger  will  present  a  slight  curve.  The  splint 
is  secured  in  position  with  strips  of  adhesive  plaster.  If  the  digit 
is  immobilized  soon  after  the  accident  the  dressings  should  not 
be  too  tightly  placed,  as  otherwise  strangulation  may  take  place 
when  the  finger  swells.  Copper  wire  may  be  used  as  a  splint,  but 
when  this  is  done  padding  should  first  be  placed  about  the  finger. 
The  most  perfect  splint  is  made  with  plaster  of  Paris  and  gauze  or 
crinoline.     (See  Figs.  440  and  441.)     This  form  of  splint  fits  the 


-_C 


Fig.   443. 


Pio 


444. 


Fig.   445. 


Fi?.   443. — The   Goldthwaite   tin,   thumb  splint  in  position.      A  layer  of   cotton  should 
be  used  to  keep  the  metal  from  coming  in  contact  with  the  skin. 

Fig.   444. — Pattern  from  which   the   Goldthwaite  splint  is  made. 

Fig.   445. — The  finger  splint  padded  and  held  in  position  by  strips   of   adhesive. 

parts  perfectly  because  it  is  moulded  to  them  and  the  finger  may 
be  placed  in  any  degree  of  flexion  according  to  the  needs  of  the 
case.  When  the  fracture  is  compound  anteriorly  the  splint  may  be 
placed  on  the  dorsal  aspect  of  the  hand  and  will  hold  the  parts 
securely. 

Compound  fractures  should  be  treated  according  to  the  prin- 
ciples laid  down  under  the  heading  of  "Treatment  of  Compound 
Fractures  and  Luxations"  on  page  789.  Ethereal  antiseptic  soap 
will  be  found  of  considerable  advantage  in  the  removal  of  dirt  and 
grease  from  the  hands  of  mechanics  and  machinists  preparatory  to 
washing  the  wound  with  salt  solution. 

Operative  Treatment. — Operation  is  rarely  indicated  in  frac- 
tures of  the  fingers  except  in  compound  cases.     The  wound  should 


312  P'RACTl'RKS    AND    DlSl.OC ATloXS 

be  treated  aeeording-  to  the  pi-iiieipU's  set  I'ortli  on  pajje  789. 
Lacerated  tissues  sliould  he  ti'iiuiiu'd  away  and  the  wound  thor- 
ouiilily  ii  rivaled  before  the  t'diies  arc  a|)|)roxiiuatrd.  If  \\w  frac- 
ture is  produced  by  some  cutting  instruiut'ut  and  tlu'  tenilons 
divided  they  shouhi  be  repaired  before  tlie  wound  is  closed.  In 
severe  crushes  of  the  fingers  amputation  may  l)e  necessary. 

After-Treatment. — Dui-ing  the  after-treatment  the  iinger  should 
be  t-ai-ftully  watched  to  keep  the  dressings  j)i'Oi)erly  adjusted  and 
to  prevent  lecurrence  of  deformity.  II  the  ti'auma  accompanying 
the  fractui'c  has  been  i;i'eat  it  may  be  l)t'st  to  postpone  the  applica- 


Fig.  446. — The  result  of  saving  too  much  of  the  finger  in  crushes  of  the  terminal 
phalanx.  The  base  of  the  nail  bed  has  been  left  which  produces  the  heavy  daw-nail 
which   is   a    continual   source   of   annoyance. 

tion  of  splints  until  the  swelling  has  subsided.  During  this  time 
the  finger  is  immolnlized  by  surrounding  the  digit  with  cotton  and 
bandaging  the  adjoining  fingers  to  it.  The  ice  cap  will  tend  to 
control  the  traumatic  reaction.  Fi.xation  should  be  maintained 
for  a  period  of  three  weeks  in  uncomi)licated  cases,  but  guarded 
passive  motion  begun  at  the  cud  of  ten  days  will  be  of  the  greatest 
advantage  in  preventing  atlhesions  within  the  joints  and  between 
the  tendons  and  their  sheaths.  In  com])ound  cases  the  greatest 
care  sliould  be  exercised  to  prevent  infection  and  suppuration  of 
the  wound  following  the  initial  treatment.  If  infection  becomes 
established  necrosis  of  bone  and  non-union  are  likely  to  follow. 
If  necrotic  bone  is  present  it  should  be  removed  as  soon  as  possible 


FRACTURES   OP    THE    FINGERS  313 

and  an  attempt  made  to  convert  the  suppurating  sinus  into  a 
healthy  wound.  If  union  is  not  present  at  the  end  of  four  or  five 
weeks  it  is  probable  that  it  will  never  occur  especially  without 
surgical  intervention.  Under  these  circumstances  it  may  be  best 
to  amputate.  In  crushes  of  the  terminal  phalanx  the  inadvis- 
ability  of  attempting  to  save  the  base  of  the  nail  bed  is  shown  in 
Fig.  446.  As  shown  in  this  case  the  nail  forms  a  heavy,  de- 
formed annoying  protuberance. 

Prognosis. — The  outlook  in  fractures  of  the  fingers  depends 
entirely  on  the  severity  of  the  injury.  In  simple  cases  recovery 
should  be  complete  while  in  severe  crushes  it  may  be  impossible 
to  avoid  amputation,  to  say  nothing  of  obtaining  union  in  the 
fractured  phalanx.  The  accompanying  injury  sustained  by  the 
soft  tissues  is  a  most  important   element. 


CHAPTER  XXIV. 

DISLOCATIONS  OF  THE  FINGERS. 

Surgical  Anatomy. — 'riie  ai'ticulations  lictwccii  the  metacarpal 
bones  anil  the  proximal  row  of  phalanges  are  condyloid  in  type 
and  permit  of  tiexion,  extension,  adduction,  abduction  and  cir- 
eumduetion.  A  variable  ainount  of  hyperextension  is  normal  in 
these  joints  and  varies  in  different  in(li\  iiluals.  These  joints  are 
lield  together  by  two  lateral  and  one  ventral  ligament.  The  place 
of  the  posterior  ligament  is  taken  by  the  extensor  tendon  which 
crosses  the  articulation.  Tlie  interphalangeal  articulations  are 
typical  hinge  joints  and  permit  only  of  flexion  and  extension.  A 
greater  degree  of  flexion  is  possible  in  the  proximal  interphalangeal 
joint  than  in  the  distal  articulation,  though  in  the  latter  a  greater 
degree  of  hyperextension  is  usually  possible.  The  ligaments  re- 
semble those  of  the  metaearpo-pludangeal  joints;  there  are  two 
lateral  and  one  ventral  ligament,  the  function  of  the  posterior 
ligament  being  performed  by  the  extensor  tendon.  The  metacarpo- 
phalangeal articulations  of  the  thvnnb  and  forefinger  are  more 
often  dislocated  than  the  three  corresponding  joints  of  the  mid- 
dle, ring  and  little  fingers  taken  together.  The  displacement  may 
be  backward,  forward,  or  lateral,  and  there  may  be  overriding  as 
well  as  angular  deformity,  and  not  infrequently  the  condition  is 
compound.  The  anterior  ligament  is  heavy  and  rigid  and  in  back- 
ward luxations  it  is  usually  torn  away  from  the  metacarpal  bone 
and  may  become  interposed  between  the  bones  and  offer  obstruc- 
tion to  reduction.  Backward  luxation  of  the  metacarpo-phalangeal 
articulation  of  the  thumb  is  not  an  uncommon  injury,  and  occa- 
sionally offers  considerable  resistance  to  reduction.  This  is  due 
to  the  interposition  of  the  anterior  ligament  and  is  probably  not 
the  result  of  the  metacarpal  head  becoming  caught  between  the 
tendons  of  the  flexors  of  the  thumb,  as  is  commonly  thought. 
An}''  of  these  luxations  may  be  complete  or  incomplete  according 
to  the  extent  to  which  the  phalanx  has  been  displaced.  Luxations 
of  the  interphalangeal  joints  are  similar  to  those  occurring  between 

314 


DISLOCATIONS   OF    THE   FINGERS 


315 


the  metacarpals  and  proximal  row  of  plialMn<ies.  The  types  of 
displacements  are  the  same  and  the  mechanism  which  obtains  is 
similar. 


Fijr.    447. — Dislocation    of   the   thumb.      Common   form. 


Fig.    448. 


Fig.    449. 


Figs.  448  and  449. — Ventral  and  dorsal  views  of  a  compound  dislocation  of  the 
terminal  phalanx  of  the  thumb.  When  an  articular  surface  is  exposed  as  this  one  is 
it  should  be  thoroughly  cleansed  before  reduction.  (See  "Operative  Treatment  of  Com- 
pound Fractures  and  Luxations,"   Chapter  LXI.) 


Fig.   450. — Old    outward    dislocation    of    thumb    which    was    never    reduced.      Picture 
taken  years  following  injury. 

Diagnosis. — The  recognition   of  these  Inxations  is  too  easy  to 
require  description.     The  patient  will  almost  invariably  diagnose 


816 


FRACTURES   AND   Pl.^LOCATIONS 


Fig.    4o2. 

Figs.  J51  and  4.'i2. — Kecent  backward  dislocation  of  tlie  second  iilialanx  of  the 
middle  finsrer  the  result  of  a  twisting  strain.  Base  of  the  second  phalanx  lies  behind 
the  head  of  the  first  phalanx.  Reduction  easily  accomplished  by  traction  and  counter- 
traction    followed    by    tiexion. 


Fig.    453. — Ventral    dislocation    of    second    knuckle.      Easily    reduced. 


Fig.  4.54. — Backward  dislocation  of  left  index  finger.  The  head  of  the  first 
phalanx  pro.iects  through  the  skin.  This  type  of  dislocation  almost  invariably  becomes 
compound  by  tearing  of  the  skin  on  the-  ventral  aspect  of  the  finger  opposite  the  joint. 


DISLOCATIONS   OF    THE    FINGERS  317 

the  nature  of  tlie  injury  before  the  surgeon  sees  liiin.  Compli- 
cating fracture  of  the  base  of  the  distal  plialanx  is,  bowever,  occa- 
sionally  oyerlooked. 

Symptoms. — The  injured  finger  is  iiuiiicilijitcly  tbrf)\vn  out  of 
function  and  the  accompanying  pain  is  usually  severe.  Tlie  de- 
formity is  apparent  and  characteristic  and  varies  according  to  the 
nature  and  direction  of  the  luxation.  The  accompanying  illustra- 
tions will  serve  to  convey  an  idea  of  the  appearance  of  these  joints 
immediately  following  the  different  forms  of  dislocation.  (See 
Figs.  447  to  455.) 


Fig.  455. — Backward  luxation  of  the  second  joint  of  the  middle  finger.  Dislocation 
rendered  compound  by  wound  on  ventral  surface  of  finger  opposite  the  .ioint.  Wound 
similar  to   that  seen  in  Fig.   454. 

Treatment. — In  simple  cases  reduction  should  be  effected  as  soon 
as  the  case  is  seen.  In  compound  luxations  the  displacement 
should  not  be  corrected  until  the  wound  and  exposed  articular  or 
synovial  surfaces  have  been  thoroughly  cleaned  and  irrigated 
with  salt  solution,  as  will  be  described  under  the  heading  of 
''Treatment  of  Compound  Fractures  and  Luxations"  on  page  789. 
The  manipulations  employed  in  reduction  vary  with  the  type  of 
displacement  and  consist  of  sliding  the  base  of  the  displaced 
phalanx  back  onto  the  head  of  the  proximal  bone.  In  a  complete 
luxation  with  overriding  deformity  traction  and  counter-traction 
may  prove  inefficient  and  when  such  is  the  case  the  angular  de- 
formity should  be  increased  until  the  edge  of  the  base  of  the  distal 
bone  is  started  onto  the  head  of  the  proximal  bone,  whether  it 


318  FRACTURES   AND    DISLOCATIONS 

be  metacarpal  or  plialanx.  The  i)riiu'iples  involved  are  similar  to 
those  employed  in  redueing  fraetures  of  the  bones  of  the  forearm 
where  the  fractured  surfaces  are  engaged  before  the  angular  de- 
formity is  corrected.  If  the  surgeon  appreciates  the  conformation 
of  the  articular  surfaces  entering  into  the  joint  and  the  nature 
of  the  displacement  there  should  be  little  difficulty  in  accomplish- 
ing reduction  in  uncomplicated  cases. 

Operative  Treatment. — Operative  treatment  is  indicated  in  eom- 
pouiul  ca.ses  and  in  instances  in  which  some  tissue,  such  as  the 
anterior  ligament,  prevents  reduction  by  manipulation.  In  com- 
pound cases  the  wound  usually  consists  of  a  transverse  tear  on  the 
ventral  aspect  of  the  joint  and  it  is  of  the  greatest  importance  that 
this  wound  be  thoroughly  cleansed  and  irrigated  before  the  luxation 
is  reduced.  If  infection  follows  a  compound  luxation  it  is  probable 
that  motion  Avill  be  lost  in  the  finger  as  a  result  of  adhesions  within 
the  joints  and  between  the  tendons  and  their  synovial  sheaths. 
(See  "Treatment  of  Compound  Fractures  and  Luxations,"  page 
789.) 

After-Treatment. — Following  reduction  the  injured  articulation 
should  be  put  at  rest  to  allow  healing  of  the  torn  ligaments. 
Earl^'  passive  motion,  however,  is  essential  to  the  subsequent 
restoration  of  function.  A  satisfactory  plan  is  to  treat  the  in- 
jured member  in  a  position  of  extension  for  the  first  three  or  four 
days  and  then  to  remove  the  dressing,  flex  the  finger  to  break  up 
forming  adhesions,  and  immobilize  it  in  this  position  for  a  similar 
period.  These  periods  of  flexion  and  extension  are  repeated  until 
the  after-treatment  is  complete.  Thus,  when  adhesions  are  In-oken 
up  within  the  joint  or  in  the  tendon  sheaths  and  the  position  of 
the  finger  changed,  the  denuded  synovial  surfaces  no  longer  remain 
opposed  and  the  chances  of  the  adhesions  reforming  are  reduced. 
A  straight  splint  may  be  used  for  the  extended  position  and  a 
roller  bandage,  such  as  is  used  in  the  treatment  of  fractures  of 
the  metacarpals  (see  page  304),  may  be  used  to  immobilize  the 
finger  in  flexion.  Healing  of  the  torn  ligaments  should  be  suffi- 
ciently far  advanced  at  the  end  of  two  weeks  to  allow  guarded  use 
of  the  injured  finger.  In  infected  cases  it  may  be  quite  difficult 
or  even  impossible  to  reestablish  motion  after  the  wound  has 
healed,  and  if  the  infection  is  .severe  it  may  necessitate  multiple 
incisions  for  the  evacuation  of  pus  along  the  course  of  the  synovial 
sheaths  and  in  the  tissues  surrounding  them. 


DISLOCATIONS   OF    THE    P^INGERS  319 

Prognosis. — In  simple  cases  restoration  of  function  should  be 
complete  with  proper  treatment  although  a  small  degree  of  flexion 
may  be  permanently  lost.  In  compound  cases  followed  by  infec- 
tion, the  prognosis  will  depend  entirely  on  the  virulence  of  the 
invading  organism,  the  resistance  of  the  patient  and  the  treatment 
he  receives.  A  serviceable  joint  may  follow  in  a  compound  in- 
fected case,  but  the  chances  of  a  stiff  finger  are  great  and  the 
patient  should  be  made  to  appreciate  this  fact  early  in  the  after- 
treatment.  If  the  infection  is  severe  amputation  may  be  neces- 
sary. 


PART  II. 
HEAD  AND  TRUNK. 


CHAPTER  XXV. 

FRACTURES  OF  THE  NOSE. 

Surgical  Anatomy. — The  bony  framework  of  the  nose  comprises 
not  only  the  two  nasal  bones,  but  also  the  nasal  processes  of  the 
superior  maxillae,  the  bony  septum  and  the  nasal  spine  of  the 
frontal.  The  nasal  bones  consist  of  two  small,  oblongs,  quadri- 
lateral bones  situated  at  the  bridge  of  the  nose.  These  bones 
articulate   laterally   with    the   processes   of   the   superior   maxillge, 


Figs.  456  and  457. — Sagittal  section  tlirou>j;li  the  nasal  cavity.  F.  R.,  Vertical 
plate  of  frontal;  JV.,  Nasal  bone:  N.  S.,  Nasal  spine;  N.P.,  nasal  process  of  superior 
maxilla;  C.  G.,  Crista  Galli ;  ,S'.  T.,  Superior  turbinate;  If.  T.,  Middle  turbinate;  I.  T., 
Inferior  turbinate;  S.,  Body  of  sphenoid;  Pal.,  Palate  bone;  P.P.,  Palatal  process  of 
superior   maxilla. 

above  with  the  frontal  (at  the  nasion)  and  in  the  median  plane 
with  each  other.  The  two  nasal  bones  meet  in  the  median  line 
and  rest  upon  the  spine  of  the  frontal  in  much  the  same  manner 
as  the  rafters  of  a  roof  rest  upon  the  king-beam.  This  nasal  spine 
is,  in  turn,  backed  up  by  the  vertical  plate  of  the  ethmoid.  This 
continuity  of  bony  tissue,  from  the  nasal  bone  to  the  christa  galli, 
explains  the  possibility  of  a  blow  on  the  nose  displacing  the  ver- 

323 


324  FRACTrRES    AND    IMSLOCATIONS 

Ti<';il  plate  of  tlio  ctlnnoid  upward  into  the  anterior  fossa  of  the 
skull.  In  young  sul),ieets  the  artieulations  in  the  bouy  fi^aniework 
of  the  nose  are  distinct  and  eontain  more  or  less  intersulural  tis- 
sue, but  in  old  age  the  sutures  are  ossified  and  the  dift'erent  bones 
become  continuous.  It  is  therefore  evident  that  in  the  aged  a 
greater  amount  of  the  trauma  of  the  nose  injuries  is  transmitted 
1()  the  vertical  plate  of  the  ethmoid  and  septal  complications  are 
more  conunon. 

Tlic  lower  half  of  the  nasal  bone  is  thinner  and  more  friable 
than  the  upper  half;  the  inferior  border  is  sharp  and  has  attached 
to  it  the  upper  lateral  cartilages  of  the  nose.  In  the  less  severe 
cases  fracture  is  limited  to  the  lower  i)ortion  of  the  nasal  bones 
because  of  the  more  exposed  position  and  weaker  construction. 

The  deep  surface  of  the  nasal  bones  is  covered  by  nuicous  mem- 
liiaiie  which  is  commonly  lacerated  in  fracture  with  displacement, 
and  hence  fractures  of  the  nasal  bones,  which  are  usually  considered 
simple  (and  are  simple  as  far  as  the  skin  is  concerned)  are  in 
reality  rendered  compound  by  laceration  of  the  mucous  lining  on 
the  deep  surface. 

The  bony  septum  is  composed  of  the  vertical  plate  of  the  eth- 
moid above  and  the  vomer  below  (see  Fig.  457). 

The  angular  interval  between  the  ethmoid  and  the  vomer  is 
filled  in  by  the  cartilaginous  septum.  This  cartilaginous  septum  ar- 
ticulates with  the  antero-inferior  border  of  the  vertical  plate  of 
the  ethmoid  and  is  continued  into  the  vomer  below.  The  junction 
of  the  cartilaginous  septum  with  the  anterior  border  of  the  vomer 
is  peculiar  because  of  the  unusual  manner  in  which  the  vomer  is 
ossified.  The  ossification  of  the  vomer  begins  in  a  single  center 
and  spreads  in  such  a  manner  that  two  lateral  plates  of  bone  result, 
with  a  median  layer  of  cartilage  between  them,  which  is  continuous 
anteriorly  with  the  quadrangular  septal  cartilage  of  the  nose. 
Union  between  the  two  lateral  plates  of  bone  does  not  take  place 
until  after  puberty.  This  peculiar  arrangement  results  in  the 
articulation  between  the  vomer  and  the  cartilage  being  stronger 
than  the  upper  articulation  between  the  ethmoid  and  the  same 
cartilage.  These  anatomical  points,  together  with  the  fact  that  the 
trauma  is  more  directly  transmitted  to  the  upper  part  of  the  sep- 
tum, account  for  the  more  frequent  displacement  taking  place 
between  the  ethmoid  and  the  quadrangular  cartilage  in  youth. 
Unless  the  interior  of  the  nose  is  carefully  inspected  earl}^  in  the 


FRACTURES   OF    THE   NOSE  325 

treatment,   septal  displacements  may  p;o  nnreeosnized   diirinji:  the 
time  that  treatment  would  be  most  efficient. 

The  angular  artery  and  vein  (continuations  of  the  facial  vessolsj 
are  found  running  in  a  nearly  vertical  direction  behind  and 
lateral  to  the  nasal  bones,  in  which  position  they  may  give  rise  to 
troublesome  hemorrhage  when  injured  in  severe  compound  frac- 
ture of  the  nose. 

The  nasal  nerve,  a  branch  of  the  ophthalmic  division  of  the 
trifacial,  runs  longitudinally  on  the  internal  surface  of  the  nasal 
bone  after  having  passed  from  the  orbit  to  the  nasal  cavity  by 
way  of  the  anterior  ethmoidal  foramen  and  nasal  slit. 

The  upper  portion  of  the  vertical  plate  of  the  ethmoid  is  grooved 
for  the  passage  of  the  ethmoidal  nerves  from  the  Sclmeiderian 
membrane  to  the  olfactory  bulb.  The  nasal  nerve  is,  strictly 
speaking,  a  nerve  of  sensation,  while  the  olfactory  nerves  have  to 
do  with  the  sense  of  smell ;  the  juxtaposition  of  these  nerves  Avith 
the  bones  involved  accounts  for  the  frequent  disturbances  of  smell 
and  sensation  following  fractures  in  this  region. 

The  mucous  membrane  of  the  nose  is  highly  vascular,  and  in 
cases  where  a  large  vessel  is  lacerated  we  may  experience  consider- 
able difficulty  in  controlling  hemorrhage. 

Etiology. — Fractures  of  the  nasal  bones  and  adjoining  bony 
structures  are  tlie  result  of  direct  violence,  such  as  blows  on  the 
face,  falls  and  trauma  sustained  by  various  means.  Fractures  of 
the  nasal  bones  constitute  between  four  and  five  percent  of  all 
fractures.  The  injury  is  most  commonly  seen  as  the  result  of 
brawls. 

Symptoms. — The  prominent  symptoms  of  fracture  of  the  nose 
are  deformity,  mobility  and  crepitus.  Swelling  of  the  soft  parts 
rapidly  follows  the  trauma  and  epistaxis  is  practically  constant 
and  appears  immediately  following  the  injury.  There  is  more  or 
less  obstruction  to  nasal  respiration,  depending  upon  the  inward 
displacement  of  the  fragments,  the  swelling  of  the  mucous  mem- 
brane and  the  accumulation  of  clotted  blood  within  the  nasal 
cavities.  The  more  extensive  the  region  involved  by  fracture  and 
the  more  pronounced  the  trauma,  the  greater  the  frequency  of 
pronounced  nasal  obstruction.  In  severe  cases  where  the  fracture 
extends  well  backward  involving  the  nasal  canal,  in  the  nasal 
process  of  the  superior  maxilla,  we  may  have  obstruction  of  the 
nasal  duct  with  consequent  lachrj'mation  of  the  aft'ected  side.     Oc- 


326 


FRACTURES   AND    DISLOCATIONS 


easioiially  we  havo  enipliysenia  of  llic  eyelids  and  face  as  a  result 
of  air  liavinuf  been   forced    fi'oin   the   nasal    jtassaiies  ijito  the  snb- 


Fig.   458. — Old  fracture  of   nasal   bones  with   lateral   displacement. 
Fig.   459. — Old   fracture   of   nasal  bones   with   lateral   displacement. 


Fig.    4G0. 


Fis.    401. 


Fig.  460. — Separation  and  angular  displarcnicnt  of  lateral  and  septal  cartilage.s  to 
patient's   right. 

Fig.  4C1. — Fracture  of  nasal  bones  with  displacement  to  right.  Partial  separation 
of  lateral  and  septal  cartilages  with  displacement  to  left. 


cutaneous  cellular  tissue.     The  nature  of  the  late  S3'mptoms  will 
vary  according-  to  the  presence  or  absence  of  infection.     The  cir- 


FRACTURES    0\P    THE    NOSE 


'421 


culation  is  extremely  free  in  this  region,  the  vitality  and  resistance 
of  the  tissues  great,  and  accordingly  we  find  recovery  more  y)rompt 
and  complete  than  might  otherwise  be  expected.  Necrotic  hone  is 
seldom  seen,  and  infections,  except  when  virulent,  are  short-lived. 
Suppuration,  however,  when  once  established,  may  persist  for 
weeks  if  there  are  particles  of  necrotic  bone  present.  The  dis- 
charge will  keep  up  until  these  pieces  have  been  removed  or 
thrown  off. 

Diagnosis. — Diagnosis  of  fracture  of  the  nose  is  based  upon  the 
symptoms  already  enumerated;  deformity,  mobility  and  crepitus. 


Fig.    463. 


Figs.   462   and  463. — Two  views  of  a  case  of  destruction  of  the   nasal  bridge  due  to 
syphilis.      Deformity  resembles   deformity  following   severe  fracture. 

Deformity,  as  observed  in  these  cases,  is  not  as  reliable  from  a 
diagnostic  standpoint  as  it  is  in  fractures  of  other  regions.  This 
fact  is  due  to  the  variability  of  the  normal  nasal  outline  together 
with  the  frequent  presence  of  old  unreduced  deformities  following 
previous  fractures. 

If  the  bridge  of  the  nose  is  gripped  between  the  thumb  and  the 
index  finger  the  stability  of  the  bones  may  be  ascertained  and 
crepitus  elicited.  The  question  of  mobility  is  rather  variable. 
During  examination  it  is  not  infrequently  possible  to  displace  the 
fragments  from  side  to  side  with  but  slight  effort :  but  on  the 
other  hand,  we  often  see  cases  in  which  the  bones  have  been  for- 


328 


FRACTURES   AND   DISLOCATIONS 


cibly  displaced  to  one  side  and  have  apparently  become  wedged, 
requiring  considerable  force  to  return  lliem  to  their  normal  rela- 
tions. A  "long  slender  instruincnt  siniilai-  1o  the  divider,  when 
properly  passed  upward  beliiiul   Hie  seat   of  fracture,   will  enable 


Fig.   464. — Fulling   in    of    cartilages    in   old    case    of    syphilis. 


Fig.    46.1. — Case   <if 


ilui'   t(i    liereditiiry   syphilis. 


the  surgeon  to  determine  the  internal  contour  of  the  nasal  frag- 
ments. The  diagnosis  of  fracture  of  the  nose  cannot  be  considered 
complete  without  ascertaining  the  coiidition  of  the  osseous  and 
cartilaginous  nasal  septum.  This  may  be  accomplished  by  direct 
inspection  or  by  palpation  with  a  probe. 


FRACTURES   OP   THE   NOSE 


329 


Treatment. — In  dealing  with  fractures  in  this  region  the  treat- 
ment must  vary  according  to  the  severity  of  the  injury.  fSevere 
compound  comminuted  fractures  may,  at  times,  become  extremely 
difficult  to  manage.  The  indications  must  be  considered  in  each 
and  every  individual  case.  Displacement,  when  present,  must  be 
corrected,  and  the  fragments  maintained  in  proper  apposition.     Re- 


Fig.  466. 


467. 


Fig.  466. — Raising  the  nasal  bones  by  means  of  "divider"  within  the  nasal  cavity 
and  moulding  them  into  position  with  the  thumb  and  index  finger. 

Fig.  467. — Packing  nasal  cavities  with  strips  of  gauze  soaked  in  adrenalin  to  control 
hemorrhage  and  support  bridge  of  nose. 

duction  is  usually  best  accomplished  by  combined  external  and 
internal  manipulation.  A  small  slender  instrument  which  will 
approximately  fit  the  posterior  surface  of  the  nasal  bone  is  passed 
upward  into  the  nose,  the  fragment  raised  and  pushed  back  into 
position,  with  the  assistance,  externally,  of  the  thumb  and  index 
of  the  opposite  hand. 


Fig.   468. — Asche  nasal   splints.      (Different   sizes.) 

Both  sides  should  be  adjusted  in  this  manner,  and  the  contour 
of  the  nose  carefully  inspected  and  palpated  to  produce  as  sym- 
metric a  result  as  possible.  At  the  same  time  we  must  be  pre- 
pared to  readjust  the  septum  when  it  shows  lateral  displacement. 
The  injuries  seen  in  the  septum  are  numerous,  involving  for  the 
most  part  the  quadrangular  cartilage  and  the  vertical  plate  of 


330 


FRACTURES   AND   DISLOCATIONS 


the  etlimoid;  the  important  point  as  far  as  treatment  is  concerned 
is  the  tendency  toward  displacement  after  the  nasal  bones  have 
been  replaced.  Lateral  bowing  of  the  septum  or  overriding  of 
the  fragments  should  be  reduced,  and  if  there  is  tendency  to  re- 
currence of  deformity  some  means  of  maintainini;'  i-eduction  must 
be  employed.  The  tubular  nasal  splint  will  often  accomplish  all 
that  is  required  but  if  some  more  secure  method  is  needed  pins 
may  be  introduced  to  hold  the  septum,  as  suggested  by  Koberts.^ 

Hemorrhage  from  the  torn  mucous  membrane  may  be  severe,  but 
even  when  moderate  at  the  time  of  examination  there  is  no  assur- 
ance that  it  will  not  be  profuse  a  few  hours  later;  it  is  therefore 


Fig.   469. — Author's    moulded,    dental    composition,    nasal    splint. 
Fig.   470. — The  Cobb  nasal  splint. 

wise  to  pack  the  upper  anterior  portion  of  the  nasal  cavity  at  the 
first  treatment.  This  will  maintain  the  fragments  in  proper  posi- 
tion and  also  serve  as  a  pack  to  control  hemorrhage  from  the 
lacerated  portion  of  the  mucous  membrane.  It  is  usually  not 
necessary  to  pack  the  parts  tightly  enough  to  bulge  the  bridge  of 
the  nose;  the  strip  of  gauze  however  should  be  carried  well  up 
under  the  nasal  bones  before  the  packing  is  begun.  ;If  these 
strips  of  gauze  are  previously  saturated  with  a  1  to  1,000  adrenalin 
chlorid  solution  we  have  an  additional  preventive  against  hem- 
orrhage. When  the  case  is  first  seen  hemorrhage  is,  as  a  rule, 
the  most  important  element  to  be  dealt  with,  and  for  this  reason 
it  is  best  to  employ  the  pack  rather  than  the  nasal  splint,  which 


1  "Surgery   of  Fractures   and  Dislocations  of   the   Nose,"    in   Sw'q.,   Oyner 
June,   19H."    John  B.  Roberts,  M.D. 


and    Oh.stet., 


FRACTURES   OP   THE    NOSE  331 

finds  a  more  appropriate  place  in  the  after-treatment  of  the  ease. 
We  should  attempt  to  reduce  deformity  immediately  following 
injury,  yet,  if  the  hemorrhage  is  pronounced,  it  should  he  con- 
trolled even  at  the  expense  of  perfect  reduction.  Later  on  when 
the  danger  of  hemorrhage  has  passed,  more  accurate  adjustment 
of  the  fragments  may  be  made,  and  one  of  the  various  forms  of 
nasal  splint,  commonly  in  use,  employed.  The  same  trauma  which 
produces  the  fracture  not  infrequently  lacerates  the  skin  over  the 
nose.  When  this  is  the  case,  we  have  the  wound  to  treat  as 
well  as  the  fracture.  Wounds  when  present  should  be  thoroughly 
cleansed  and  the  edges  approximated.  If  the  margins  of  the 
wound  show  much  laceration  the  ragged  edges  should  be  trimmed 
away  with  a  sharp  scalpel  before  the  sutures  are  placed.  Either 
local  or  general  anesthesia  is  advisable  except  in  the  most  mild 
type  of  case.  If  the  nose  is  gently  packed  for  a  few  minutes 
with  strips  of  gauze  saturated  in  a  four  percent  solution  of  co- 
caine, subsequent  manipulations  will  be  rendered  almost  free  from 
pain  and  the  surgeon's  work  is  made  much  easier. 

Operative  Treatment.^ — There  is  little  in  the  way  of  operative 
treatment  in  these  cases  aside  from  that  already  described.  There 
are  exceptional  cases,  however,  in  which  it  may  be  necessary  to 
reconstruct  the  bridge  of  the  nose  or  to  correct  old  deflections  of 
the  septum  or  nasal  bones  which  have  resulted  from  old  unre- 
duced fractures.  Pronounced  depression  may  result  either  from 
the  original  trauma  or  from  subsequent  infection  and  sloughing. 
Syphilis  is  still  another  cause  of  falling  of  the  bridge  or  cartilages 
and  the  resultant  deformity  should  not  be  confused  with  the  trau- 
matic condition.  Syphilitics  often  misrepresent  their  case  and 
unless  the  surgeon  recognizes  the  luetic  nature  of  the  condition, 
he  may  perform  a  plastic  operation  on  the  nose  of  an  active 
syphilitic,  while  the  specific  processes  are  still  destructive. 

In  correcting  deflections  and  depressions  of  the  bridge  an  at- 
tempt is  made  to  bring  the  displaced  portions  of  bone  back  into 
position  after  having  refractured  them  as  near  as  possible  to  the 
original  seat  of  fracture.  Much  can  be  accomplished  in  the  lower 
portion  of  the  bone  by  incisions  through  the  mucous  membrane  on 
the  deep  surface  of  the  bones.  When  the  deflection  begins  high 
up  near  the  frontal  refracture  may  be  accomplished  by  a  small 
subcutaneous  incision  and  narrow  chisel.  After  the  displaced 
fragments  have  been  refractured  they  are  brought  back  into  posi- 


332  FRACTURES    AND    DISLOCATIONS 

tion  and  trcati^d  tlic  snino  as  a  recent  fi-acture.  The  septum  re- 
quires attention  and  wluii  defleeted  it  nia\  become  necessary  to 
do  a  submucous  resection,  as  is  done  for  deflections  resulting  from 
causes  other  tha^i  fracture.  Tu  some  cases  of  saddle  nose  there  is 
not  sufficient  bony  tissue  from  whicli  to  reconstruct  the  bridge  and 
the  problem  then  becomes  one  not  only  of  plastic  surgery  but  also 
of  bone  transplantation.  A  bone  transplant  of  appropriate  size 
and  shape  is  taken  from  tbe  erest  of  the  tibia,  introduced  within 
the  tissues  of  the  nose  and  the  soft  parts  closed  over  it  according 
to  tlie  plastic  method  best  suited  to  the  case  in  hand.  AVhen  the 
bone  transi)lant  is  used  it  should  be  sha[)ed  and  placed  to  fit  the 
needs  of  the  particular  case,  and  tlie  denuth'd  osseous  material  of 
the  transplant  should  be  brou^lit  firmly  in  contact  with  the  de- 
nuded surface  of  tlie  living  l)oiie,  so  that  the  reformative  osteo- 
genetic  elements  may  find  their  way  from  tlie  living  bone  into  the 
transplant  during  the  process  of  repair.  The  injection  of  paraffin 
to  correct  nasal  depression  has  often  been  followed  by  satisfactory 
results,  but  on  the  wliole  cannot  be  reconnnended  except  in  rare 
cases. 

The  most  satisfactory  suture,  except  where  there  is  considerable 
tension  of  the  parts,  is  horse-hair. 

After-Treatment. — The  gauze  packs  should  not  be  allowed  to 
renunn  in  place  more  than  forty-eight  hours  at  the  most  and  we 
should  exercise  the  greatest  gentleness  in  their  removal  in  ordei- 
that  we  may  avoid  the  recurrence  of  hemorrhage.  If  the  packs 
are  allowed  to  remain  longer  they  become  foul,  thus  favoring  in- 
fection and  suppuration.  We  occasionally  meet  with  cases  in 
which  both  primary  and  secondary  hemorrhage  are  difficult  to 
control.  If  hemorrhage  follows  the  removal  of  the  packs,  the 
inside  of  the  nose  is  to  be  inspected  to  determine  whether  we  have 
a  general  oozing  or  a  hemorrhage  from  a  single  vessel.  In  cases 
where  loss  of  blood  from  a  single  vessel  is  persistent  it  may  become 
advisable  to  touch  the  bleeding  end  with  a  small  electro-cautery. 
"When  the  dangers  of  hemorrhage  and  infection  are  past  the  re- 
maining desideratum  consists  in  maintaining  the  fragments  in 
position  until  union  has  taken  place.  In  most  cases  the  simple 
nasal  splint  (Asche  splint)  fitted  into  the  upper  nares  will  suffice. 
A  slight  degree  of  pressure  may  be  maintained  from  the  outside 
by  strips  of  adhesive  plaster  applied  across  the  bridge  of  the 
nose.     Various  types  of  complicated  external  nasal  sj^lints   (such 


FRACTURES   OF    THE   NOSE  333 

as  the  Cobb,  Eisendrath,  Neres,  etc.)  have  been  devised  and  used 
with  success,  but  it  is  only  in  rare  instances  that  they  are  of  real 
service. 

When  external  pressure  is  necessary  to  maintain  the  fragments 
in  proper  position  we  may  employ  the  following  method  which 
is  quite  efficient  and  simple.  A  piece  of  dental  composition,  hav- 
ing been  rendered  pliable  by  immersing  it  in  hot  water,  is  applied 
to  the  nose  and  a  mould  of  the  parts  taken  with  such  pressure  as 
may  be  necessary  to  maintain  proper  reduction.  Cold  water  is 
then  poured  over  the  composition  to  harden  it  before  removing 
it  from  the  nose.  The  newly  formed  splint  is  then  removed  and 
trimmed  as  desired,  after  which  it  is  replaced  and  secured  by  means 
of  strips  of  adhesive  plaster  (see  Fig.  469).  If  thought  desirable, 
additional  leverage  may  be  obtained  by  extending  the  splint  up- 
ward onto  the  forehead  where  it  is  again .  secured  by  transverse 
strips  of  adhesive.  It  is  better  not  to  employ  any  form  of  moulded 
splint  until  after  the  acute  swelling  has  subsided,  which  will  take 
from  three  to  four  days; — on  the  other  hand,  delay  beyond  the 
fifth  or  sixth  day  is  not  advisable  since  union  in  this  region  is 
often  rapid.  External  pressure,  however,  is  rarely  needed  if  the 
essentials  previously  mentioned  are  properly  followed  out.  Union 
should  take  place  in  the  average  adult  in  from  ten  days  to  two  and 
a  half  weeks  but  it  will  be  over  a  month  and  a  half  to  two 
months  before  the  parts  should  be  subjected  to  any  considerable 
pressure,  and  the  patient  should  be  cautioned  in  this  regard. 
During  the  course  of  after-treatment  the  internal  nasal  splints 
should  be  removed  at  intervals  of  three  to  four  days,  and  nasal 
douches  employed  daily  to  prevent  the  parts  from  becoming  foul. 
Normal  salt  solution  or  one  of  the  mild  alkaline  antiseptic  washes 
will  be  found  satisfactory  as  a  douche.  Subcutaneous  emphysema, 
ecchymosis  and  swelling  will,  as  a  rule,  subside  during  the  first 
few  days  without  the  use  of  any  special  method  for  their  relief. 

Prognosis. — The  prognosis  is  almost  invariably  good,  yet  we 
cannot  guard  too  carefully  against  infection  in  this  region.  The 
deformity  is  almost  always  a  matter  subject  to  correction  and  aside 
from  exceptional  cases  the  ultimate  cosmetic  results  should  be 
good. 


CHAPTER  XXVI. 

FRACTURES   OF   THE  MALAR  BONE   AND 
ZYGOMATIC  ARCH. 

Surgical  Anatomy.  Aiuitoinically  speaking  the  malar  is  a 
distinct  bone,  but  from  a  surgical  standpoint  it  becomes  neces- 
sary to  consider  the  various  processes  with  which  it  articulates  as 
a  part  of  that  bone,  since  fractures  are  rarely  limited  to  the 
malar  alone.  The  bone  is  roughly  quadrilateral  in  shape,  articu- 
lates with  the  frontal,  great  wing  of  the  sphenoid,  zygomatic 
process  of  the  temporal  and  the  malar  process  of  the  superior 
maxilla.  It  also  forms  part  of  the  wall  of  the  temporal  and 
zygomatic  foss?e  and  enters  into  the  formation  of  the  orbit.  The 
bone  is  composed  of  heavy  compact  tissue,  its  strength  being  such 
that  blows  on  the  face  usually  result  in  impaction  of  its  supports 
rather  than  fracture  of  the  bone  itself.  The  fact  that  the  malar 
enters  into  the  formation  of  the  wall  of  the  orbit  and  the  zygo- 
matic fossa,  will  lead  to  symptoms  peculiar  to  these  cavities  when 
the  bone  is  displaced.  From  a  surgical  standpoint  the  zygomatic 
arch  is  to  be  considered  as  a  whole,  and  since  the  zygomatic  process 
of  the  temporal  and  the  malar  both  enter  into  its  formation,  these 
two  structures  are  spoken  of  as  one.  The  space  beneath  this  arch 
is  normally  filled  by  the  coronoid  process  of  the  inferior  maxilla 
and  the  temporal  muscle,  and  any  inward  displacement  of  the 
arch  must  encroach  upon  these  structures  and  interfere  with  their 
function.  Interference  with  the  action  of  the  lower  jaw  may  some- 
times result  from  the  extravasation  of  blood  or  from  swelling  of 
the  tissues  beneath  the  arch,  and  we  thus  have  a  symptomatic 
simulation  of  bony  depression.  So-called  fracture  of  the  malar 
consists  chiefly  in  impaction  of  the  bone  into  tlie  processes  sup- 
porting it,  especially  that  of  the  superior  maxilla.  The  largest 
process  supporting  the  bone  is  the  malar  process  of  the  superior 
maxilla,  and  since  the  antrum  of  Highmore  projects  well  up  into 
this  process  (sometimes  even  penetrating  into  the  malar)  the  frac- 
ture may  open  into  the  cavity  of  the  antrum ;  when  such  is  the 

334 


FRACTURES    OP    MAIjAR    B()NI«:    AND    ZYGOMATIC    ARCH  835 

case  the  manner  in  which  air  may  be  forced  from  the  nasal  cavity, 
through  the  antrum,  into  the  conjunctiva,  is  evident.  Thus  the 
resulting  subconjunctival  emphysema,  when  present,  indicates  the 
condition  of  the  underlying  bone. 


Fig.   471. — Relations  of  the  nasal,  lachrymal,   superior  maxilla   and  malar  bones. 


Fig.    472. — Zygomatic  arch  seen  from  below.      Note  the  relations  of  the  arch  and  tlie 
inferior  maxilla. 

In  fracture  of  the  malar  the  usual  deformity  consists  in  depres- 
sion of  the  bone  into  the  superior  maxilla  with  a  slight  rotars^  dis- 
placement, so  that  the  orbital  border  may  be  felt  projecting  into 
the  orbit  while  the  zygomatic  process  is  displaced  inward  and 
downward    (see    Fig.    471),     The    malar   is   sometimes    displaced 


386  FRACTURES   AND   DISLOCATIONS 

directly  backward  so  that  the  zygomatic  surface  encroaches  on  tlic 
space  normally  occupied  by  the  temporal  muscle  and  coronoid 
process.  The  condition  is  rare  but  wlioii  jtrcsont  may  interfere 
with  the  function  of  tlie  lower  jaw. 

The  infraorbital  canal  runs  close  to  the  plane  of  suture  between 
the  superior  maxilla  and  the  malar,  and  when  the  latter  is  im- 
pacted into  the  former  we  may  have  injury  to  the  nerves  contained 
within  the  canal:  namely  the  antero-superior  dental,  the  middle 
superior  dental,  and  the  libres  which  are  later  continued  into  the 
terminal  branches.  Accordingly,  disturbances  in  sensation  may 
occur  in  the  uppt'r  teeth  and  gums  as  far  ])ack  as  the  second  bi- 
cuspid (inclusive)  and  in  the  tenniiial  l)raii('lies  of  the  infraorbital 
on  the  face. 

The  subcutaneous  tissue  covering  this  region  is  loosely  cellular 
and  devoid  of  fascia,  thus  permitting  of  pronounced  and  rapid 
swelling  which  is  so  frequently  a  hindrance  to  diagnosis. 

The  muscles  attached  to  this  bone  are  three  in  nnmlu'r;  two  of 
them,  the  zygomaticus  major  and  minor  are  muscles  purely  of 
expression,  and  hence  disturbances  in  their  function  will  be  diffi- 
cult to  recognize;  but  the  masseter,  attached  to  the  postero-inferior 
border,  is  a  muscle  of  mastication,  and  disturbance  in  this  func- 
tion is  readily  detected. 

The  malar  bone  is  sometimes  normally  divided  into  two  parts 
by  a  horizontal  suture,  which  anomaly  should  not  be  mistaken  for 
fracture  during  operation  or  while  exploring  wounds. 

The  postero-superior  border  of  the  bone  is  continuous  with  the 
temporal  crest  of  the  frontal  above,  with  the  upper  border  of  the 
zygoma  below  and  has  the  heavy  temporal  fascia  attached  to  it 
throughout  its  extent.  The  antero-superior  border  forms  the  lower 
and  outer  margin  of  the  orbit  and  in  this  position  is  easily  {Pal- 
pated, as  is  the  postero-inferior  border  of  the  bone. 

Etiology. — Fracture  of  the  malar,  like  fracture  of  the  nasal 
bones,  is  the  result  of  direct  violence,  such  as  falls  and  blows  on 
the  face.  It  requires  a  much  greater  degree  of  violence,  however, 
to  fracture  the  malar  than  it  does  the  nasal  bones. 

Symptoms. — Pain  is  a  constant  element,  while  mobility  and 
crepitus  are  more  often  absent  than  present.  Swelling  is  usually 
rapid  and  pronounced,  and  ecchymosis  about  the  eye  common. 
The  patient  will  usually  give  a  history  of  severe  trauma  and  may 
present  a  number  of  variable  sj'mptoms  according  to  degree  and 


FRACTURES    OK    MAIjAR    HONK    AND    ZY(;(JM  A'IMO    AROJI 


337 


direction  of  the  displaccinciit.  If  tlic  anterior  ami  middle  deidal 
branches  of  the  superior  maxillar.y  no've  have  been  injured  there 
may  be   considerable    joain,    niiiiijjiicss   and    tiii^linK    of   the    f.nims 


Fig.  473. — Fracture  of  the  left  malar  bone  a  few  minutes  after  injury.  Note  the 
swelling  about  the  left  eye  and  the  way  the  examining  finger  sinks  into  the  left  side  of 
the  face.  A  number  of  air  blebs  were  seen  beneath  the  conjunctiva  twenty-four  hours 
later,  the  air  having  gained  entrance  to  the  tissues  through  the  antrum. 


Fig.  474. — Fracture  of  left  malar  bone  twenty-four  hours  after  injury.  Note  how 
the  finger  sinks  into  the  patient's  face  beneat'.i  the  swollen,  ecchymotic  eye.  A  portion 
of  the  infraorbital  ridge   is   depressed   and  may  be  paljiated. 

and  teeth  of  the  affected  side  as  far  back  as  second  bicuspid  (in- 
clusive). Fractures  of  the  zygomatic  arch  or  a  backward  dis- 
placement of  the  malar  may  be  accompanied  by  disturbances  in 


338 


FRACTURES   AXD   DISLOCATIONS 


fum-tion  of  the  inaiidiblo.  Tliere  may  he  iciiii  in  the  aft'ectod  side 
on  niastioation ;  in  severe  cases  the  patient  itiay  he  totally  unable 
to  move  the  jaw.  The  characteristic  symptom  will  consist  ol'  a 
depression  of  the  malar  or  zygomatic  arch  with  a  corresponding 
tlattening  of  the  cheek;  this  symptom  however  may  be  masked  by 
swelling,  within  a  few  minutes  of  the  injury,  and  unless  a  care- 
ful examination  is  made  at  the  time,  the  true  condition  may  be 
overlooked.  Conjunctival  ecchymosis  is  usually  present  and,  in 
some  cases,  conjunetival  emphysema. 


Fie.  475. — Fvactiire  of  the  iju^i.nor  jiDition  of  the  mnlar  and  the  anterior  end 
of  the  "zygoma  on  the  left  side  of  the  face.  Note  how  the  examining  finger  sinks  into 
the  depression  and  compare  it  with  the  finger  on  the  corresponding  point  on  the  un- 
injured side.  Eye  swollen  shut  and  conjunctiva  blood-shot.  Photograph  a  few  min- 
utes following  the  injury. 

Diagnosis.— If  the  swelling  is  not  great  the  examination  and 
diagnosis  should  be  easy.  The  deformity  which  results  from  the 
depression  of  the  malar  or  zygomatic  arch  is  masked  during  the 
acute  stage  by  the  swelling,  and  unless  a  careful  examination  is 
made  to  determine  the  condition  and  position  of  the  underlying 
bone  we  may  learn  subsequentl.y  to  our  chagrin  what  the  real  de- 
formity is,  after  the  swelling  has  subsided  and  union  has  taken 
place.  Inspection  alone,  in  these  cases,  is  valueless  since  the  vis- 
ible symptoms  are  the  same  as  seen  in  ordinary  "black  eye" 
(ecchymosis  and  swelling).  We  should  therefore  carefully  pal- 
pate the  parts  to  determine  the  position  of  the  underlying  bone. 
In  most  cases,  continued  pressure  with  the  finger  will  displace  the 
intracellular  inflammatorv  fluids  suffieientlv  to  allow  the  surgeon 


FRACTURES   OF   MALAR   BONE   AND   ZYGOMATIC    ARCH  339 

to  satisfactorily  appreciate  the  conditions  present,  and  to  compare 
them  with  the  facial  contour  of  the  uninjured  side.  The  two 
sides  can  best  be  compared  by  standing  behind  the  patient  and 
palpating  both  bones  simultaneously  with  the  thumb  and  index 
finger  of  each  hand  (see  Fig.  473).  The  presence  of  depression 
can  be  determined  by  placing  the  two  index  fingers  over  the  prom- 
inent portion  of  the  cheeks,  and  comparing  the  two  sides;  suffi- 
cient pressure  on  the  injured  side  should  be  made  to  allow  the 
finger  to  sink  in,  in  order  that  we  may  eliminate  the  swelling 
which  is  otherwise  misleading.  The  orbital,  temporal  and  masse- 
teric borders  may  be  palpated  and  the  position  of  the  bone  thus 
determined  and  compared.  The  conjunctiva  should  be  examined 
for  the  purpose  of  detecting  ecchymosis  or  emphysema ;  the  former 
is  by  no  means  pathognomonic,  but  the  latter  is  the  result  of  air 
having  passed  from  the  nasal  cavity  into  the  conjunctiva,  which 
is  impossible  if  the  bones  of  the  face  are  intact. 

Treatment. — The  first  indication  in  the  treatment  of  these  cases 
is  to  counteract  the  local  effects  of  trauma  and  to  relieve  pain, 
when  severe.  The  inflammatory  reaction  can  be  maintained  at 
the  minimum  by  the  use  of  the  ice-bag  for  the  first  twelve  to 
twenty-four  hours.  In  most  cases,  an  attempt  to  correct  the  de- 
formity is  purely  for  cosmetic  reasons,  and  in  considering  this 
element  we  must  take  into  consideration  the  surroundings  of  the 
case. 

For  example :  deformity  resulting  from  depression  of  the  malar 
may  be  deemed  an  extremely  important  matter  in  the  case  of 
the  young  society  woman,  while,  on  the  other  hand,  the  average 
laborer  would  not  consider  for  a  moment  the  trouble,  time  and 
expense  necessary  for  the  correction  of  the  disfiguration  which  in 
no  way  interferes  with  his  earning  capacity.  "When  no  attempt 
is  made  at  correcting  the  displacement  the  case  resolves  itself 
firstly,  into  the  control  of  local  reaction ;  secondly,  allowing  nature 
to  unite  the  impacted  fragments;  and  thirdlj^,  the  treatment  of 
accompanying  wounds  when  present.  If  the  fracture  is  compound 
as  a  result  of  direct  violence  the  wound  should  be  cleansed  and 
the  edges  approximated  according  to  general  surgical  principles 
as  applied  to  the  treatment  of  wounds  and  compound  fractures. 
"When  complications  exist,  such  as  interference  with  the  action  of 
the  jaw,  or  extreme  and  prolonged  pain  in  the  region  of  the 
superior  dental  nerves,  operation  is  indicated. 


340  FRACTURES    AXO    niST.onATKINS 

Operative  Treatment. — Operation  may  become  necessary  for 
cosmetic  reasons  or  for  tlie  alleviation  of  complications  such  as 
the  interference  with  llic  iM-lion  of  Wu'  }:\w -.  the  type  of  operation 
will  depend  to  some  extent  on  the  reasons  for  which  it  is  under- 
taken.  When  performed  for  cosmetic  reasons  only,  open  incision 
slioukl  be  avoided,  because  of  the  resultant  scar.  In  these  cases, 
the  bone  may  be  approached  from  the  mouth  through  an  incision 
parallel  with  the  alveolai-  process  and  opposite  the  malar  process 
of  the  superior  maxilla,  thi'  thick  part  of  which  may  be  felt  oppo- 
site the  first  molar.  Tiiis  incision  is  carried  up  under  the  cheek 
until  the  malar  is  exposed,  after  wdiich  it  is  i)ried  back  into  posi- 
tion and  the  incision  closed.  Another  method  is  that  of  making 
a  small  incision  through  the  skin,  drilling  a  hole  in  the  face  of 
the  malar  and  inserting  a  screw,  by  w^hich  means  the  bone  may 
be  raised  and  replaced.  Any  modification  of  an  intraoral  opera- 
tion should  be  conducted  with  due  consideration  for  asepsis  and 
followed  by  frequent  douchiugs.  Deformity  has  been  successfully 
corrected  by  the  subcutaneous  injection  of  paraffin,  though  the 
method  is  somewhat  ciuestionable.  The  difficulty  with  operative 
treatment  is  not  so  much  a  cjuestion  of  replacing  the  bone  as  it 
is  of  maintaining  it  in  its  original  position,  and  the  reason  for 
this  difficulty  is  explained  by  the  loss  of  bony  tissue  which  takes 
place  in  impaction.  In  other  words  it  is  not  difficult  to  reduce 
the  deformity,  but  w'e  do  not  have  the  supporting  process  intact 
to  maintain  reduction  after  the  impaction  has  been  broken  up. 
In  Lothrop's  operation  the  bone  is  approached  through  the  mouth 
as  previously  described,  the  depression  corrected  and  the  antrum 
packed  with  gauze  to  maintain  the  malar  in  its  elevated  position. 
The  gauze  is  left  in  place  for  four  or  five  days.  The  cavity  is 
packed  a  second  time — if  there  is  tendency  toward  a  recurrence 
of  the  deformity — and  left  for  a  second  period  of  four  or  five  days. 
The  danger  in  this  operation  consists  of  infection,  which  is 
favored  by  allowing  the  ])acks  to  remain  during  the  period  indi- 
cated. Some  of  the  more  recent  work  done  with  bone  transplants 
w^ould  suggest  the  use  of  bone  wedges  taken  from  the  tibia  to 
support  the  malar  in  its  raised  position,  the  wound  being  closed 
without  drainage.  Fracture  and  depression  of  the  zygomatic  arch 
call  for  reposition  of  the  fragments;  this  is  most  satisfactorily 
accomplished  by  means  of  a  direct  incision  exposing  the  bone. 
If  tile  incision  is  made  parallel  to,  and  a  short  distance  above  the 


PRACTtJRES    01^    MAT.AR    liONE    AND    ZYfiOMATK!    ARCIf 


841 


Fig.  476. — Depressed  fracture  of  right  maJar  of  two  years'  standing.  Note  hollow 
under  patient's  right  eye.  Deformity  moderate.  Compare  this  deformity  with  that 
seen  in  case  shown  in  Figs.   477   and  478. 


478. 


Figs.  477  and  478. — Old  depressed  fracture  of  the  right  malar  with  pronounced  de- 
formity. Note  the  flattened  cheek  which  is  best  appreciated  in  profile.  Patient  gives 
history   of   severe   direct  violence   with  i^ractically   no   treatment   following   same. 


342  J'KACTL'RES   AND   DISLOCATIONS 

arch  we  can  frcciuciitly  replace  the  bone  and  still  have  the  resultant 
scar  m  a  position  which  will  be  covered  by  the  hair  after  recovery 
is  complete.  Care  should  be  taken  to  accurately  approximate  the 
temporal  fascia"  before  closing  the  wound.  Sensory  disturbances 
in  the  course  of  the  dental  nerves  will  usually  clear  up,  but  when 
severe  may  call  for  operative  intervention  to  relieve  the  pressure. 
Pain  in  the  terniinal  branches  of  the  infraorbital  nerve  can  some- 
times be  control k-d  by  a  hypodermatic  injection  of  alcohol  into  the 
nerve  as  it  emerges  from  the  iufi'aoi-lntal  foramen. 

After-Treatment. — The  after-treatment  in  the  ordinary  case 
consists  of  the  avoidance  of  additional  trauma,  and  allowing 
Nature  to  unite  the  fragments.  No  retentive  apparatus  is  neces- 
saiy  and  dressings  are  not  called  for  except  in  compound  cases. 
The  mouth  and  nose  should  be  kept  clean  by  the  use  of  antiseptic 
douches  to  avoid  the  possibility  of  infection  by  way  of  the  antrum. 

Prognosis. — Deformity  is  a  common  result  of  fracture  of  the 
malar,  and  even  though  operative  intervention  may  reduce  the 
displacement  it  is  rarely  possible  to  return  the  fragments  perfectly 
to  their  original  positions.  Neuralgias  may  follow  the  condition, 
but  usually  subside  within  a  few  months  even  if  allowed  to  go 
untreated.  Interference  with  the  action  of  the  lower  jaw  follow- 
ing depression  of  the  arch  is  a  condition  which  has  been  followed 
by  recover^'  of  function  even  in  cases  where  no  treatment  has  been 
employed. 


CHAPTER  XXVII. 

FRACTURES  OF  THE  SUPERIOR  MAXILLA. 

Surgical  Anatomy. — The  superior  maxilla  may  be  considered  the 
shell  which  forms  the  wall  of  the  antrum  of  Highmore,  and  from 
this  shell  we  have  projecting  in  various  directions,  processes  of 
bone  which  articulate  with  the  adjoining  bones  of  the  face  and 
cranium.  The  different  regions  into  which  these  processes  project 
and  their  several  functions  render  the  subject  of  fracture  of  this 
bone  diverse. 

The  nasal  process  extending  upward,  inward  and  backward,  ar- 
ticulates with  the  nasal,  lachrymal,  frontal  and  ethmoid  bones,  and 


Fig.   479. — Superior    maxilla.      A'^.,    nasal    process;     M.,    malar    process;     O.,    orbital 
process;  I.F.,  infraorbital  foramen;   A. A.,   alveolar  process.      (See  Fig.  471.) 

enters  into  the  formation  of  the  nasal  cavity,  the  orbit,  the  anterior 
ethmoidal  cells  and  the  lachrymal  canal.  Fracture  of  this  process 
is  associated  with  fracture  of  the  nasal  bones  and  for  surgical 
purposes  is  to  be  considered  under  fractures  of  the  nose. 

The  alveolar  -process  is  thick  and  arched  and  is  hollowed  out  into 
sockets  corresponding  in  number,  depth  and  width  to  the  sixteen 
upper  teeth.  A  portion  of  the  alveolar  arch  is  not  uncommonly 
fractured  in  the  extraction  of  teeth,  but  the  injury  is  not.  as  a 
rule,  of  serious  import  provided  the  line  of  fracture  is  confined 
to  this  process. 

343 


344  FRACTURES   AND   DISLOCATIONS 

•The  malar  process  is  thick,  composed  of  a  heavy  tissue,  supports 
the  malar  bone  and  sustains  most  of  the  impaction  when  the  malar 
is  driven  into  the  face.  It  is  therefore  best  considered  witli  frac- 
tures of  the  malar. 

The  palatal  process  forms  the  greater  part  of  the  roof  of  the 
mouth  and  in  this  position  is  rarely  subject  to  injury.  It  is  some- 
times, however,  fractured  by  falls  on  objects  held  in  the  month, 
and  is  not  infrequently  the  site  of  suicidal  gunshot  injury. 

Fracture  of  the  body  of  the  hone  may  occur  from  blows  on  the 
face  especially  in  instances  in  which  the  malar  is  impacted  into  its 
substance.  Fractures  of  the  body  involve  the  antrum  of  Ilighmore 
and  are  therefore  compound  connecting  with  the  outer  air  through, 
the  nasal  cavity.  In  comminuted  fractures,  especially  gunshot  in- 
juries, the  fragments  may  be  driven  into  any  adjoining  cavity 
(orbit,  nasal  cavity,  zygomatic  fossa,  temporal  fossa,  mouth)  or 
they  may  be  displaced  into  the  antrum  itself.  We  may  have  a 
vertical  line  of  fracture  separating  the  bones  of  the  two  sides,  or 
a  horizontal  fracture  disarticulating  the  maxilla  from  the  frontal. 
Another  form  of  horizontal  fracture  situated  at  a  lower  level, 
separates  the  alveolar  and  palatal  processes  from  the  rest  of  the 
bone.  Such  fractures  are  necessarily  the  result  of  severe  direct 
violence,  such  as  a  fall  from  a  height  or  a  kick  from  a  horse.  The 
relation  of  the  antral  cavity  to  the  surface  of  the  bone,  and  the 
manner  in  which  the  palate,  inferior  turbinate,  and  ethmoid  close 
in  the  opening  between  the  antrum  and  the  nose  are  of  surgical 
importance  as  regard  drainage  in  cases  of  infection.  The  antrum 
may  be  entered  by  way  of  the  nose,  through  the  canine  fossa,  or 
b}^  extraction  of  the  first  or  second  molars.  The  circulation  in  the 
region  of  the  face  is  extremely  free,  accounting  for  the  rarity  with 
which  necrosis  occurs  in  the  fragments  and  the  manner  in  which 
loosened  teeth  regain  their  solidity.  A  considerable  portion  of 
the  superior  maxilla  is  covered  with  mucous  membrane,  which  is 
usually  torn  if  the  fracture  involves  this  region ;  we  should  there- 
fore examine  the  nasal  and  oral  cavities  in  making  a  diagnosis. 

Symptoms. — Deformity  is  very  variable  and  may  be  entirely 
masked  by  the  swelling  which  is  likely  to  be  pronounced  and  fol- 
lows the  injury  rapidly.  The  most  common  displacement  consists 
in  depression  of  the  fragments,  the  face  being  "driven  in"  to  a 
greater  or  less  extent,  in  the  region  of  the  injury.  Hemorrhage 
from  the  nose  or  mouth  is  prone  to  occur,  and  emphysema  is  some- 


FRACTURES   OF    SUPERIOR    MAXILTiA 


345 


times  seen  as  a  result  of  air  having  been  forced  into  the  tissues 
from  either  the  oral  or  nasal  cavities.  Depression  in  the  region  of 
the  antrum  is  most  common.  Mobility  and  crepitus  are  variable 
and  their  absence  should  not  lead  us  to  exclude  fracture.  Loss  of 
alignment  in  the  teeth  and  mobility  of  a  section  of  the  alveolar  arch 
are  usually  present  when  the  fracture  involves  this  process.  The 
symptoms  in  general  will  vary  greatly  according  to  the  region  of 
the  bone  involved  and  the  associated  injury  of  the  soft  part.  We 
sometimes  see  cases  in  which  the  face  is  so  severely  crushed  that 
it  is  no  longer  a  question  of  which  of  the  facial  bones  is  fractured 
but, — have  any  escaped? 


Fig.  480. — ^Fracture  of  superior  maxilla.  Patient  injured  iu  automobile  wreck. 
Fracture  extends  through  alveolar  process,  body  of  bone  and  through  the  orbital 
process.  Posterior  fragment  displaced  downward  as  may  be  seen  by  the  disturbed 
dental   alignment. 


Diagnosis. — The  upper  jaw  is  examined  in  a  manner  similar  to 
the  malar.  The  outline  of  the  upper  portion  may  be  palpated 
through  the  face  and  its  two  sides  compared.  The  lower  portion 
of  the  bone  and  the  teeth  may  be  examined  through  the  mouth,  and 
the  lateral  wall  of  the  nasal  cavity  inspected  through  the  nostril. 
Mobility  may  rarely  be  elicited  by  making  pressure  on  the  face  in 
various  direction.     Crepitus  is  likewise  an  uncommon  symptom. 

Treatment. — The  treatment  of  fracture  of  the  superior  maxilla, 
like  the  symptoms,  varies  according  to  the  region  of  the  fracture. 
Fracture  of  the  nasal  process  is  treated  similarly  to  fracture  of  the 
nasal  bone,    and   is   included   under   that  heading.     Fracture    of 


346  FRACTURES   AND   DISLOCATIONS 

the  nialai-  process  is  a  condition  very  similar  to  so-called  fracture 
of  the  malar,  and  is  treated  in  a  like  manner.  Fracture  of  the 
body  of  the  bone  frequently  calls  for  some  method  of  elevating 
the  depressed  fragment,  and  this  may  often  be  accomplished 
through  the  mouth,  thus  avoiding  a  scar  of  the  face.  Fracture  of 
the  superior  maxilla  is  very  eonnnonly  associated  with  severe  lac- 
erated wounds  of  the  face,  and  when  such  is  the  case  we  have  the 
wound  to  deal  with  in  addition  to  the  fracture  itself.  The  vitality 
of  the  tissues  is  high  on  account  of  the  free  circulation,  and  ac- 
cordingly it  W'ill  seldom  be  necessary  to  remove  fragments  of  bone 
or  to  trim  away  torn  tissue  unless  manifestly  devitalized.  Lac- 
erated wounds  of  the  face  should  be  freely  washed  with  normal 
salt  solution  in  order  to  remove  infectious  material  which  has  been 
driven  into  the  tissues,  and  wounds  of  the  mucous  membrane  com- 
municating with  the  fracture  through  the  mouth  should  be  fre- 
quently and  freely  irrigated  in  order  to  avoid  subsequent  infection. 
Fracture  of  the  alveolar  arch  is  to  be  treated  according  to  the  re- 
quirements of  each  individual  case.  When  there  is  no  tendency 
toward  displacement  of  the  fragments  the  chief  indication  is  that 
of  cleansing  with  a  mild  alkaline  solution.  If  there  is  displace- 
ment of  teeth  and  disturbed  occlusion  through  loss  of  alignment  it 
may  become  necessary  to  hold  the  fragments  in  position  by  wiring 
the  teeth  or  by  means  of  an  aluminum  dental  splint  as  described 
in  the  treatment  of  "Fracture  of  the  Lower  Jaw"  (page  357). 
Separation  of  the  two  superior  maxillai  may  also  be  immobilized 
in  the  same  manner.  Openings  through  the  palatal  process  should, 
except  in  eases  of  simple  fissure,  be  protected  from  the  mouth  dur- 
ing the  process  of  healing  by  a  hard  rubber  plate.  In  gunshot 
injuries,  the  area  of  fracture  may  be  protected  from  contamina- 
tion by  food,  and  the  nasal  and  oral  cavities  separated  in  this 
manner. 

Operative  Treatment. — Operative  treatment  is  indicated  in 
severe  compound  cases.  It  will  be  impossible,  however,  to  lay  down 
any  hard  and  fast  lines  of  procedure,  since  the  needs  of  eacli  and 
every  individvial  case  will  vary,  and  the  surgeon  will  find  it  neces- 
sary to  meet  the  demands  of  the  case  in  hand. 

After-Treatment. — The  chief  indication  of  after-treatment  will 
be  to  keep  the  parts  clean,  prevent  infection  and  allow  nature  to 
unite  the  fragments.  In  the  presence  of  infection  we  should  see  to 
it  that  the  antrum  is  freely  drained ;  this  may  be  accomplished  b}' 


FRACTURES   OF   SUPERIOR    MAXILLA  347 

the  extraction  of  the  first  or  second  molar  or  by  perforating , the 
anterior  wall  of  the  antrum  above  the  roots  of  these  teeth.  The 
antrum  may  also  be  entered  and  drained  through  the  inferior  or 
middle  meatus ;  when  the  opening  is  made  through  the  inferior 
meatus  it  may  be  necessary  to  previously  remove  the  inferior 
turbinate.  During  the  early  part  of  the  after-treatment  the  nose 
should  be  irrigated  three  to  four  times  daily  and  the  oral  cavity 
should  receive  equally  careful  attention. 

Prognosis. — Union  usually  takes  place  in  from  six  weeks  to  two 
months.  Prognosis  as  to  life  is  good  except  in  severe  crushing 
injuries  of  the  face  in  which  shock  is  great,  and  associated  injuries 
of  the  skull  and  brain  probable.  The  prognosis  as  to  deformity 
is  frequently  not  good  in  fracture  of  the  body  of  the  bone.  Frac- 
ture of  the  nasal  process  can  usually  be  treated  without  subsequent 
deformity.  Fracture  of  the  malar  process  is  not  so  favorable  in 
this  respect. 

The  presence  of  infection  renders  the  prognosis  worse  but  if 
proper  treatment  be  established  without  delay  and  etficient  drain- 
age and  lavage  maintained  the  outcome  should  in  most  cases  be 
good.  In  fracture  of  the  alveolar  process  small  sloughs  of  bone 
may  require  removal  but  this  does  not  siguif}^  that  the  ultimate 
outcome  will  not  be  good. 


CHAPTER  XXVIII. 

FRACTIREJ^  OF  THE  LOAYEK  JAW. 

Fracture  of  the  lower  jaw  is  a  common  injiuy,  constituting  nearly 
four  percent  of  all  fractures,  and,  since  the  bad  results  so  often 
seen  are  due  to  mechanical  and  anatomical  causes,  it  is  evident  that 
an  intimate  understanding-  of  the  anatomy  of  the  parts  is  essential 
to  the  successful  treatment  of  this  fracture. 

Surgical  Anatomy. — The  inferior  maxilla  or  mandible  is  the 
largest  and  strongest  bone  of  the  face  and,  with  the  exception  of 
the  nasal  bones,  is  most  frequently  fractured.  It  is  composed 
of  the  body,  ramus,  and  two  processes;  the  coronoid  and  condylar. 


Figs.  481    and   482. — Two   views   of    the   mandible. 
Coronoid  process;  A.,  Angle  of  jaw;   ,S'.,  Symphysis. 


Con.,    Condyloid   process;    Cor., 


Its  jiosition  is  ver.y  much  exposed  to  violence,  but,  on  the  other 
hand,  there  are  numerous  elements  which  render  the  bone  capable 
of  withstanding  considerable  trauma  without  fracture.  Its  weight 
is  considerable  and  the  structure  heavy,  its  mobility  great,  and  the 
buffer-like  action  of  the  interarticular  fibro-cartilage  of  the  tem- 
poro-maxillary  articulation  serves  to  maintain  the  integrity  of  the 

348 


FRACTURES   OP   LOWER    JAW  349 

bone  in  the  presence  of  a  blow.  In  addition  the  horseshoe  shape 
of  the  body  imparts  a  certain  spring  to  the  bone  which  is  pro- 
tective. The  manner  in  which  the  fragments  of  the  body  are  dis- 
placed will  depend  on  the  muscles  attached  to  the  bone.  To  the 
external  surface  in  the  region  of  the  chin,  we  have  the  levator 
menti,  while  along  the  external  oblique  line  are  seen  the  attach- 
ments of  the  depressor  labii  inferioris,  depressor  anguli  oris  and 
platysma  myoides.  These  muscles  with  the  exception  of  the  last 
named  extend  upward  toward  the  chin,  are  small,  and  of  minor 
importance  in  displacements.  The  buccinator  is  attached  to  the 
alveolar  margin  opposite  the  three  molars.  The  masseter,  a  pow- 
erful muscle,  occupies  the  external  surface  of  the  ramus,  and  pulls 
in  an  upward  direction.  The  coronoid  process  is  taken  up  by  the 
insertion  of  the  temporal  muscle,  which  has  a  displacing  action 
similar  to  that  of  the  masseter.  The  internal  surface  of  the  body 
has  the  mylo-hyoideus  arising  from  the  mylo-hyoid  ridge,  and  the 
genial  tubercles  have  attached  to  them  the  genio-hyoglossus  and 
the  genio-hyoideus.  One  of  these  muscles  enters  directly  into  the 
formation  of  the  tongue,  while  the  remaining  two  are  attached  to 
the  hyoid  bone  and  when  their  anterior  bony  attachments  are  dis- 
placed backward,  as  is  sometimes  the  case  in  bilateral  fractures, 
we  have  backward  falling  of  the  tongue.  This  condition,  espe- 
cially during  unconsciousness,  may  cause  asphyxia  if  the  tongue 
is  not  pulled  away  from  the  epiglottis  by  direct  forward  traction 
on  the  tongue  itself,  or  by  drawing  the  displaced  fragment  for- 
ward. To  the  posterior  surface  of  the  symphysis  below  the  genial 
tubercles  we  have  the  diagastric  muscles  attached  on  either  side. 
The  pull  of  this  pair  of  muscles  is  downward,  backward  and 
slightly  outward.  The  superior  constrictor  of  the  pharynx  has  an 
attachment  internal  to  and  behind  the  last  molar.  The  internal 
pterygoid  is  attached  to  the  deep  surface  of  the  ramus  in  the 
region  of  the  angle,  while  the  external  pterygoid  is  attached  to 
the  internal  surface  of  the  condylar  process.  These  muscles  have 
a  lateral  displacing  action  in  fractures  of  the  lower  jaw :  the  com- 
mon inward  displacement  of  the  posterior  fragment  is  largely  due 
to  the  unopposed  action  of  the  internal  pterygoid.  The  temporal 
and  masseter  produce  the  usual  upward  displacement  of  the  pos- 
terior fragment.  As  a  result,  therefore,  of  the  combined  action  of 
these  muscles  the  posterior  fragment,  in  fractures  of  the  body, 
will  usually  be  displaced  upward  and  inward    (see  Figs.  485  to 


350  FKAl'TIHKS    AND    DISLOCATIONS 

489).  Accord iiip:ly  in  the  correction  of  the  deformity  and  during 
the  subseciuent  inuiiobilization  of  the  fragments  it  is  the  disphicing 
action  of  these  muscles  \\itli  wliicli  we  have  to  contend. 

In  fracture  of  tlie  body  of  the  bone  wide  displacement  of  the 
fragments  is  usually  prevented  by  the  line  of  fracture  passing 
through  the  attachment  of  some  of  the  muscles,  especially  the  mylo- 
hyoideus  which  is,  as  a  rule,  attached  to  botli  sides  of  the  line  of 
fracture.  The  masseter  and  internal  ]iterygoid  tend  in  like  man- 
ner to  limit  the  separation  of  fragments  when  the  ramus  is  frac- 
tured. 

On  the  internal  surface  of  the  ramus  we  liavc  the  inferior  dental 
foramen  for  the  passage  of  Hie  inferior  dental  nerves  and  vessels 
Avhich  pass  through  the  substance  of  the  bone  supplying  the  teeth 
of  the  lower  jaw.  Injuries  to  these  structures  sometimes  occur, 
though  not  as  commonly  as  might  be  inferred.  The  long  root  of 
the  canine  and  the  mental  foramen  are  both  considered  elements 
of  weakness  in  the  structure  of  the  inferior  maxilla ;  it  is  in  this 
region  that  fracture  most  frequently  occurs.  The  mucous  mem- 
brane is  torn  in  most  cases  of  fracture  of  the  body  and  accordingly 
the  break  is  usually  compound. 

It  should  be  remembered  that  the  facial  artery  passes  onto  the 
external  surface  of  the  body  of  the  bone  just  anterior  to  the  antero- 
inferior angle  of  the  masseter  muscle.  From  a  point  behind  the 
posterior  border  of  the  ramus  of  the  jaw  we  have  the  beginning 
of  the  pes  anserinis,  comprising  the  motor  fibres  running  to  the 
various  muscles  of  the  face.  Stenson's  duct  runs  directly  forward 
from  the  parotid  gland  and  empties  opposite  the  second  upper 
molar.  The  positions  of  the  artery,  nerve  and  duct  are  of  impor- 
tance when  the  fracture  is  accompanied  by  wounds  of  the  face. 
In  fractures  of  the  condylar  process  the  upper  fragmiMit  may  be 
displaced  forward  and  inward  by  the  action  of  the  external 
pterygoid  pulling  in  the  direction  of  the  external  pterygoid  fossa. 
Fracture  of  the  coronoid  is  extremely  rare,  occurring  only  in  con- 
junction with  fracture  of  other  bones  in  this  region,  such  as  the 
zygomatic  arch.  It  is  said  however  to  have  been  broken  as  a  result 
of  muscular  action. 

Etiology. — Direct  violence  is  responsible  for  most  fractures  of 
the  inferior  maxilla.  Fractures  due  to  indirect  violence  are  seen 
in  instances  in  which  the  sj'mphysis  has  been  fractured  by  lateral 
compression,  the  condyle  broken  off  by  a  blow  on  the  chin  and 


FRACTURES   OF   LOWER    JAW 


351 


in    avulsion    of   the    coronoid    tuljercle,    as    a    result    of    muscular 
action. 

Symptoms. — The  symptoms  of  fracture  of  the  inferior  maxilla 
will  depend  upon  the  following  conditions:  the  region  of  the  break, 


Fig.  483. — Fracture  of  mandible  at  sympliysis.  Mobility  apparent  on  palpation  or 
when  patient  attempts  to  speak.  Arrow  indicates  line  of  fracture.  Right  central 
incisor   loose. 


Fig.   484. — X-ray    plate   of    same    case    showing   line    of   fracture. 


the  degree  of  the  causative  trauma,  and  the  displacing  action  of 
the  muscles  attached  to  the  fragments.  There  will  be  swelling, 
tenderness,  pain,  deformity,  abnormal  mobility,  loss  of  function 
and  crepitus.  Swelling  is  usually  pronounced  and  follows  the  in- 
jury rapidly.     Tenderness  and  pain  are  present  in  the  region  of 


FKACTl'KKS    AND    1)1SI,(  ICATIOXS 


Fig.  485. — Fi'acture  of  the  lower  jaw  just  anterior  to  the  right  canine.  Note  the 
upward  displacement  of  the  posterior  fragment.  The  dark  shadow  between  the  lower 
teeth  and  lip  is  blood  which  is  coming  from  the  fractured  surfaces  and  torn  mucous 
membranes.  Photograph  taken  shortly  following  accident.  Arrow  indicates  line  of 
fracture. 


^ 


Ife 


Fig.    486. — Fracture  of   lower  jaw   at    the  point  indicated   by   the   arrow, 
alignment  of  the  lower  teeth. 


Note  loss  of 


FRACTURES   OF    LOWER    JAW 


353 


the  break,  and  are  increased  by  any  attempt  at  using  the  jaw. 
The  deformity  accompanying  the  usual  fracture  in  the  neiglibor- 
hood  of  the  canine  is  characteristic :  the  posterior  fragment  is  dis- 
placed upward  and  inward,  and  loss  of  alignment  in  the  teeth 
(except  in  edentulous  cases)  is  apparent  upon  examination.  Frac- 
ture behind  the  last  molar,  in  the  I'anuis  or  in  the  condyle  is  rarely 
seen,  but  when  it  does  oc(nir  the  deformity  is  less  cnsily  detected. 


Fig.  487. — Fracture  of  the  lower  Jaw  about  twenty-four  hours  following  injury. 
Line  of  fracture  passes  between  tlie  lateral  incisor  and  canine  on  the  left  side.  Note 
how  the  posterior  fragment  is  raised.  In  this  instance  the  fracture  is  a  little  oblique 
so  that  the  fractured  surfaces  have  engaged  in  such  a  manner  that  the  posterior  frag- 
ment  is   prevented  from  the   usual   inward   displacement. 


The  anterior  border  of  the  ramus,  however,  may  be  palpated  from 
within  the  mouth  with  little  difficulty  even  in  cases  where  swelling 
of  the  face  is  pronounced  enough  to  prevent  opening  the  mouth. 
In  such  cases  the  finger  is  passed  between  the  cheek  and  the  teeth, 
and  carried  back  far  enough  to  determine  the  outline  of  the  an- 
terior margin  of  the  ramus.  In  addition  to  direct  palpation  we 
may  detect  abnormal  mobility  by  placing  the  fingers  of  one  hand 


354 


FRACTI"REP;    AND    DIST.OCATIONS 


on  the  ramus  of  the  jaw  cxti-i'iiallx .  while  the  ()p|)o.site  liand  moves 
the  chin.  Fi-acturc  in  the  rejjion  oL"  {\\^i  sympliysis  is  readily  de- 
tected by  inspection  and  palpation.  The  functions  of  mastication 
and  articulation  are  interfered  with  from  the  first  and  on  account 
of  the  subsequent  inflammatory  reaction  become  projiressively  more 
pronounced  in  the  earlier  fttap^es  of  the  condition.  Crepitus  can, 
in  most  cases,  be  elicited,  but  is  usuall\'  not  iicccssarx-  in  dia<jfnosti- 


Fig.  488. — Fracture  of  lower  ,i:iw  inunediately  following  injury.  Line  of  fracture 
passes  between  the  second  bicuspid  iiiid  the  first  molar  on  the  right  side.  Note  how  the 
posterior  fragment  is  displaced  inward  and  remains  raised  when  the  mouth  is  opened  as 
a  result  of  the  unopposed  ac-tions  of  the  right  temporal  and  masseter  muscles.  This 
is  the  usual  deformity  and  should  be  particularly  guarded  against  in  the  treatment. 
If  the  deformity  is  allowed  to  go  uncorrected  there  will  result  faulty  dental  alignment, 
malocclusion  and  the  chin  will  be  displaced  toward  the  in.iured  side.  The  further 
back   the    line   of   fracture   the   greater   the   leverage   of   the   displacing   muscles. 


eating  the  condition.  We  should  only  attempt  to  produce  crepitus 
after  other  means  of  ascertaining  the  presence  of  fracture  have 
failed ;  the  less  the  fragments  are  manipulated  the  better  it  is  for 
the  patient.  The  usual  case  presents  a  characteristic  picture :  the 
patient  suffering  considerable  local  pain  presents  himself  for  treat- 
ment because  of  severe  injury  sustained  in  the  region  of  the  jaw, 
one  side  of  the  face  shows  swelling,  and  maj^  or  may  not  be  accom- 
panied by  a  wound.     The  lips  and  teeth  are  slightly  separated,  the 


FRACTURES   OF   LOWER    JAW 


355 


Fig.  489. — Fi-tioture  of  the  right  siilc.  of  iiunulible  about  six  weeks  after  injury 
and  after  union  had  taken  place.  First  seen  by  author  at  this  time.  In  this  case  the 
inward  displacement  of  the  posterior  frag-raent  caused  by  the  internal  pterygoid  muscle 
has  been  allowed  to  go  uncorrected  and  nialocclusion  and  displacement  of  the  chin 
toward  the  injured  side  has  resulted.  The  displacement  of  the  chin  is  best  appre- 
ciated when  the  jaws   are  closed. 


Fig.  490. — Fracture  of  the  mandible  behind  the  last  molar  on  the  left  side.  Pos- 
terior fragment  displaced  upward  so  that  the  fractured  surface  may  be  seen.  Photo- 
graph retouched.  Anterior  surface  of  raised  posterior  fragment  outlined  to  direct  atten- 
tion to  its  position.  Reduction  accomplished  through  incision  at  the  angle  of  the  jaw  and 
wiring  of  the  fragments.      Case  seen  with  Dr.   H.   R.  McGraw. 


356 


FRACTURES   AND   DISLOCATIONS 


patient  is  unable  to  talk  with  any  deg:ree  of  distinctness,  saliva 
drools  from  the  month,  and  on  inspecting  the  teeth  we  find  the 
characteristic  .upward  and  inward  disi)lacement  of  the  posterior 
fragment  with  loss  of  dental  alignment.  Manipulation  of  the 
p.-irts  increases  the  sutl'eriiiu'.     If  the  case  has  been  allowed  to  go 


Fig.    491. — lvont<j:fnuy;i;iiii 
loosened  and  displaced  last  niol; 


.similar   tu   the  one   shown   in  Fig.    490.      Note   the 


untreated  for  a  few  days  we  have  added  to  the  above  symptoms 
those  of  putrefactive  changes  within  the  oral  cavity ;  there  is  a 
foul,  characteristically  offensive  odor,  and  pus  may  be  mingled 
with  the  saliva. 

Diagnosis. — The  presence  of  fracture  can  almost  always  be  deter- 
mined by  palpation  and  inspection.  The  diagnosis  is  based  on  the 
presence  of  the  symptoms  just  enumerated.  The  condition  is  usu- 
ally so  easy  to  recognize  that  it  is  common  for  the  i)atient  to  make 
the  diagnosis  before  he  is  seen  by  the  surgeon.  Fi-acture  of  a 
portion  of  the  alveolar  arch  accompanying  the  extraction  of  teeth 
sometimes  goes  unrecognized.  Probing  the  socket  will  usually  de- 
termine the  condition  if  fragments  are  present.     Fracture  of  the 


FRACTURES   OP   LOWER    JAW  357 

ramus  or  condyle  in  some  cases  calls  for  the  use  of  the  X-ray,  to 
clear  up  the  diagnosis. 

Treatment. — Fracture  of  the  inferior  maxilla  is  a  condition 
which  has  been  treated  from  time  immemorial  with  poor  or  in- 
different success ;  it  is,  however,  only  within  recent  years  that  more 
accurate  and  satisfactory  results  have  been  attained,  due  to  the 
introduction  of  improved  methods,  such  as  the  intraoral  splint  in 
its  various  modifications,  wiring  the  jaws  together,  and  direct  op- 
erative procedures.  Reduction  of  the  displacement  is  usually  easy 
but  the  difficulty  arises  Avhen  we  come  to  immobilizing  the  frag- 
ments. The  different  methods  employed  all  attempt  the  attain- 
ment of  two  ends:  firstly,  the  reduction  and  permanent  cor- 
rection of  the  deformity,  and  secondly,  the  prevention  of  infection. 
The  various  principles  followed  and  appliances  devised  to  accom- 
plish these  results  are  too  numerous  to  mention ;  we  will  consider 
under  the  following  headings  only  those  which  have  been  found 
most  satisfactory. 

1.  Simple   binding   of  the  lower   jaw   against   the   upper   by 

means  of  the  fourtailed  bandage. 

2.  Some  form  of  interdental  splint  and  the  fourtailed  band- 

age.     (Gunning.) 

3.  Dental  splint  with  arms  attached  for  counter-pressure  be- 

neath the  jaw.     (Kingsley,  Achland,  Matas.) 

4.  Dental  splint  cemented  to  the  teeth.     (Heath.) 

5.  Wiring  the  lower   to  the   upper   teeth.     Oliver's  method, 

Simple  wiring.  Angle  bands  with  wire. 

6.  Securing  the  fragments  by  means  of  wiring  the  teeth  of  the 

lower  jaw. 
Wiring  of  teeth  adjacent  to   fracture.     Hammond's   wire 
splint.  Angle  bands  with  connecting  bar. 

7.  Operative    treatment.     Direct    wiring    or    plating    of    the 

fragments.     Bone  transplantation. 

All  of  these  methods  have  their  points  of  advantage  and  their 
drawbacks,  but  from  among  them  we  are  enabled  to  select  tb.e  one 
best  suited  to  the  case  in  hand. 

1.  Simple  hiudinfj  of  the  lower  jaw  to  the  upper  is  the  oldest 
method  known  and  in  the  presence  of  modern  facilities  is  onh' 
mentioned  to  be  condemned.  As  an  emergency  method,  however, 
it  has  its  uses  and  will  tend  to  keep  the  fragments  at  rest  and  more 


358  FRACTURES   AND    DISLOCATIONS 

or  less  opposed  until  some  more  accurate  means  can  be  employed. 
Its  disadvantage  consists  in  its  persistent  tendency  to  loosen,  which 
may,  to  some- extent,  be  corrected  by  strips  of  adiiesive  plaster 
placed  over  the  cloth  after  the  bandage  has  been  applied.  The 
dressintr  may  be  tightened  in  this  manner  as  often  as  it  becomes 
loose  durinu'  the  after-treatment.  A  fourtailed  bandage  may  be 
made  entirely  of  adhesive  as  follows:  a  three-inch  strip  of  adhesive 
long  enough  to  encircle  the  head  (from  the  chin  to  the  laml)da) 
one  and  one-half  times,  is  split  on  either  end  leaving  a  solid  piece 
of  about  two  inches  in  the  middle.  This  middle  piece  is  applied 
to  the  chin,  the  head  having  been  previously  covered  by  a  layer 
of  gauze.     The  two  lower  tails  are  carried  upward  and  slightly 


Fig.   492.  i'ig.   493. 

Pig.  492. — Four-tailed  bandage  made  with  adhesive  plaster.  Head  has  been  cov- 
ered with  gauze  to  prevent  adhesive  coming  in  contact  with  hair. 

Fig.  493. — Same  with  superfluous  gauze  cut  away.  Dressing  completed.  More 
convenient  and  neat  than  either  the  ordinary  four-tailed  bandage  or  the  plaster 
bandage. 

backward,  and  attached  to  the  gauze  with  sufficient  traction  to 
secure  the  lower  jaw  against  the  upper.  The  upper  pair  of  tails 
is  then  carried  backward  to  meet  and  overlap  in  the  occipital 
region.  (Figs.  492  and  493.)  After  this  has  been  done  the  super- 
fluous gauze  is  trimmed  away  and  we  have  a  dressing  much 
more  secure  than  the  ordinary  fourtailed  bandage.  During  the 
after-treatment  the  dressing  may  be  tightened  by  additional  strips 
of  adhesive  without  disturbing  the  parts.  In  securing  the  lower 
jaw  to  the  upper  in  this  manner,  extreme  care  must  be  taken  to 
keep  the  mouth  clean  during  the  after-treatment.  The  approxi- 
mation of  the  lower  teeth  to  the  upper  in.sures  perfect  occlusion, 
but  the  employment  of  external  pressure  alone  is  too  insecure  to 


FRACTURRK   OP    r/)WER    .JAW 


359 


be  relied  upon  and  must  l)e  accompanied  by  some  additional 
method  o£  internal  fixation. 

2.  Interdental  splint  with  fourtailed  bandage. 

Various  materials  have  been  used  for  interdental  splints  but  none 
have  been  found  as  serviceable  and  satisfaelory  as  vuh^anized  rub- 
ber. The  production  of  tiie  hard  rubber  interdental  splint  (Gun- 
ning) requires  a  certain  amount  of  laboratory  techni([ue,  familiar, 
as  a  rule,  only  to  the  dentist;  when  such  services  can  be  detained 
by  the  surgeon  the  treatment  is  rendered  much  easier.  In  making 
a  vulcanite  interdental  si)lin.t  it  is  necessary  first  to  take  impres- 


Fig.   494. — Interdental    splint    of    vulcanite    with    opening    for    feeding    of    liquids. 

sions  of  the  upper  and  lower  dental  arcades.  These  impressions 
may  be  taken  in  wax,  dental  composition,  or  plaster.  After  the 
impressions  have  been  taken  a  counter-impression  of  each  is  made 
with  plaster  of  Paris.  These  counter-impressions  of  the  upper 
and  lower  teeth  are  next  properly  trimmed  and  mounted  respec- 
tively on  the  upper  and  lower  arms  of  a  dental  articulator.  Then 
by  means  of  a  fine  saw  the  lower  cast  is  cut  in  the  region  of  the 
fracture,  and  the  portions  of  the  cast  representing  the  fragments 
are  brought  back  into  alignment.  The  reduction  is  next  tested 
by  closing  the  articulator,  thus  bringing  the  lower  teeth  against 


360  FRACTURES   AND   DISLOCATIONS 

tlu'  upper.     Further  corrections  nnist  be  nuule  when  necessary  for 
the  production  of  perfect  occlusion.     When  proper  occlusion  Avith 
the   upper   teeth    i.s   produced    we   have   the   exact   ])osition   which 
should  be  occupied  by  tlie  frauniculs  of  the  mandible.     Tlie  sawed 
pDrtions  of  tlie  lower  cast  are  then  Jixed  with  plaster  in  the  cor- 
rected  position,   after  which   the   articulator   is  opened   until   the 
easts  are  in  the  same  relative  positions  which  tlie  upjicr  and  lower 
jaws  should  occupy  during  the  after-treatment.     The  interval  be- 
tween the  upper  and  lower  dentures  is  then  filled  in  with  bees- 
wax and  worked  out  in  detail  of  the  size  and   proportion  desired 
for  the  interdental  splint.     Openings  in  the  splint  for  the  admis- 
sion of  food  must  be  provided  for.     The  two  easts  together  with 
the  intervening  wax  are  next  removed,  being  cut  in  such  a  manner 
that  only  that  portion  of  each  cast  representing  the  teeth  and  gums 
is  included.     The  two  cut-down  casts  with  intervening  wax  form 
are  then  placed  in  a  vulcanizing  flask    (their  relations  being  un- 
disturbed),  and   plaster  poured  into  the  flask  until   it  rises  half 
way  up  the  wax  form.     This  is  allowed  to  set  and  dry  after  which 
the  surface  is  shellacked  and  covered   with   powdered  soapstone. 
The  second  half  of  the  mould  is  then  made  by  pouring  in  plaster 
which  is  allowed  to  set ;  then  the  two  moulds  are  separated  and 
the  wax  melted  out  with  hot  water.     When  the  wax  is  removed 
we  have  a  cavit}^  in  each  mould  which  when  taken  together  cor- 
respond to  the  built-up  wax  form  which  was  made  on  the  articu- 
lator.    These   cavities   are  then   packed   with   dental    rubber,   the 
moulds  put  together  again  and  placed  in  a  vulcanizing  flask,  the 
process  now  being  the  same  as  that  employed  in  making  the  ordi- 
nary dental  plate.     When  vulcanization  is  complete  the  splint  is 
removed  for  flnishiug  and  polishing,  after  which  it  is  ready  for 
use.     This  form  of  splint  is  particularly  useful  when  other  meth- 
ods would  be  unsatisfactory  because  of  partial  or  complete  loss  of 
teeth.     When  the  patient  wears  a  complete  set  of  false  teeth  these 
may,  by  proper  alteration,  be  used  as  a  splint  during  the  after- 
treatment  of  the  fracture,  or  a  splint  may  be  made  by  impression 
from  that  portion  of  the  plate  coming  in  contact  with  the  gums. 
Wedges  of  dental  composition  or  gutta-percha  may  be  used  be- 
tween the  teeth  as  splints.     They  are  much  more  easily  applied 
but   are  not  as  satisfactory  as  the  vulcanite   splint,   and   do   not 
allow  the  drinking  of  hot  liquids  while  in  use. 

3.  Dental  splint  with  arms  for  counter-pressure  henaiih  the  chin. 


FRACTURES   OF   LOWER   JAW 


361 


^The  chief  representatives  under  this  heading  are  the  appliances 
devised  by  Kingsley,  Ackland  and  Matas. 

Kingsley's  appliance  is  a  moulded  splint  conforming  with  the 
irregularities   of  the   inferior   dental   arcade  and   holds  the   frag- 


Fig.   495. — Metal  dental  splint  with  arms  for  counter-pressnre  by  means  of  bandages 
passing  beneath  the   lower   jaw. 


Fig.   496. — Vnleanite    splint    with    arms    for    counter-pressnre. 

ments  in  reduction  by  means  of  counter-pressure  beneath  the  chin. 
Two  lateral  arms  are  secured  to  the  splint  which  emerge  through 
the  mouth  and  afford  attachment  laterally  for  bandages  passing 
under  the  jaw.     The  body  of  the  splint  may  be  made  of  various 


362 


FRACTURES  AND   DISLOCATIONS 


materials,  and  the  tccliiii(|ii»'  of  pi-odiictidi;  will  \ary  accord- 
iiigfly. 

Acklaiid's  s|)liiit  consists  ol'  a  iiictal  uiiltcr  partly  lilK'd  with 
"■iitta-perclia  wliidi  wlicii  sol'tt'iird  takes  tlie  inipi'int  of  the  lowei' 
teeth.  The  intraoral  jiortion  of  the  api)aratus  is  lield  in  position 
by  means  ot"  ehiinps  wliieli  make  eoimter-pressiire  beneath  the  chin. 

The  Matas  splint  (see  Fig-.  497)  consists  ol"  an  ad.jnstable  clamp 
to  be  api>lied  to  the  lower  jaw.  The  intraoral  arm  carries  a  block 
tin  form  which  is  ti'iuimed  and  bent  to  lit  the  teeth  while  the 
lower  arm  caiM'ies  a  ix'i-foralcd,  ad.jnstahli',  aluniinum  clnn  piece 
for  couiitei'-])ressui-e.  The  inti'aoral  bloci^  tin  form  is  notched  to 
facilitate  bentling  and  tittino'  to  the  teeth;  this  gutter  may  be  filled 


Fig.  497. — The  ^[;^t;^.s  spVint.  An  excellent  aiipm-atus  for  the  treatment  of  cer- 
tain fractures  of  the  lower  jaw.  This  splint  is  adjustable  and  is  sujiiilied  with  differ- 
ent sizes  of  chin  plates  and  dental  splints. 

with  giitta-i)ei'cha  or  dental  composition  to  obtain  more  lirm  and 
accurate  contact  between  teeth  and  splint.  This  splint  will  give 
very  satisfactory  results  in  the  usual  fracture  of  the  body  and  may 
be  applied  with  little  difficulty. 

The  three  splints  just  described  together  with  the  one  following 
have  the  common  advantage  of  allowing  motion  of  the  lower  jaw 
during  the  after-treatment.  Soft  food  may  be  masticated  aftei-  the 
first  few  days  and  the  patient  has  litth;  difficulty  in  talking.  The 
splint  j)ossessing  these  advantages  in  the  greatest  d(;gree  is  the 
following : 

4.  Dental  splint  cemented  to  the  teeth.     (Heath.) 
This  splint  is  made  of  metal  according  to  principles  similar  to 
those  just  described  in  producing  the  vulcanite  splint.     The  dif- 


FRACTURES   OP   LOWER    JAW 


'>H:'> 


Fiff.   498. — Metal    dental    splint    for    cementing    to    the    lower    teeth. 


Pig  499. — Same  splint  with  the  teeth  in  occlusion.  In  placing  this  splint  lu  posi- 
tion the  greatest  care  should  be  exercised  to  see  that  both  splint  and  teeth  are  thor- 
oughly dry,  as  otherwise  the  cement  will  not  hold.  The  mucous  surfaces  are  walled 
away  with  sheet  cotton. 


364 


FRACTURES  AND  DISLOCATIONS 


fereiice  in  material,  liowcvci-.  will  necessitate  an  altered  laboratory 
teehniqiie,  whieh  is  as  follows:  jilaster  easts  of  the  two  dental 
arcades  are  made  and  the  deformity  in  the  lower  one  corrected 
as   descrilicd    uiidcr    hcadiii!^'   No.    2,    page   ;}5!).     The    cast    of   the 


Fig.  500. — Edmund's  forceps  un-  rlaiuiiiiiir  iii<'t:il  sjiliiit  to  tlir  l.asrs  i\i  tlii>  tppth. 
Slipping  of  the  instrument  imd  injury  to  tlie  gums  and  alveolar  process  is  prevented 
by  the  set-screw  between  the  jaws  which  engages  the  crown  of  the  tooth. 

lower  denture  is  built  up  so  as  to  do  away  with  all  undercuts,  after 
which  it  is  shellacked,  dusted  with  soapstone  and  demoiuited  from 
the  articulator.  A  counter-impression  is  next  made  from  it  in 
oiled   sand   and   the   die   formed  bv   filliiiu'   this   sand    mould    with 


Fig.  501. — Cast  aluminum  splint  cemented  to  the  teeth  for  tlie  fixation  of  a 
fracture  of  the  lower  jaw  at  the  symphysis.  In  making  this  splint  the  patient's  "bite" 
was  taken  in  wax  and  the  splint  made  from  this  so  that  the  upper  surface  occludes 
with  the  upper  teeth.  Lack  of  occlusion  between  the  splint  and  tlie  upper  teeth  is 
uncomfortable    and    annoying   to    the    patient    during    the   after-treatment. 

molten  zinc.  After  cooling  the  die  is  removed,  inverted  in  the 
moulding  flask  and  packed  about  witli  sand  so  that  the  tips  of  the 
teeth  alone  are  exposed.  Molten  lead  is  then  poured  into  the  flask 
to  form  the  first  or  shallowest  counterdie.     Three  or  four  counter- 


FRACTURES   OP   LOWER    JAW  365 

dies  of  graded  depths  should  be  made.  Tliis  is  accomplished  by 
lowering  the  level  of  the  sand  in  the  flask,  thus  exposing  a  greater 
portion  of  the  die  to  the  molten  lead.  The  splint  is  made  by 
swedging  metal  between  the  die  and  countcrdie.  The  most  shallow 
counterdie  is  used  first  to  start  the  metal  of  the  splint,  after  which 
the  deeper  eounterdies  are  used  in  ordej'  until  by  means  of  the 
deepest  or  complete  counterdie  the  metal  of  the  splint  is  forced 
into  perfect  form.  Aluminum,  silver  or  gold  may  be  used  in 
making  the  splint.  After  swedging  is  completed  th(!  splint  is 
trimmed  so  that  the  edges  will  not  impinge  on  the  gums  or  cut 
the  tongue.  The  final  step  consists  in  polishing,  after  which  the 
splint  is  ready  for  use.  The  hollow  side  of  the  splint  is  then  filled 
with  cement  and  forced  onto  the  teeth,  care  being  taken  to  pre- 
vent the  cement  from  being  driven  downward  between  the  gums 
and  teeth.  The  fixation  of  the  splint  to  the  teeth  is  rendered  more 
secure  by  the  use  of  Edmund's  forceps  (see  Fig.  500)  before  the 
cement  sets.  This  instrument  is  used  to  clamp  the  splint  about 
the  bases  of  the  teeth,  the  set  screw  preventing  the  sharp  jaws 
from  slipping  down  onto  the  gums. 

This  splint  fits  the  crowns  of  the  lower  dental  arcade  and  is 
attached  to  them  by  means  of  oxophosphatic  cement  which  requires 
about  one-half  hour  to  become  firmly  set.  During  this  time  dis- 
placement is  to  be  guarded  against  by  firmly  holding  or  binding 
the  lower  jaw  to  the  upper.  This  method  requires  considerable 
laboratory  technique  but  when  the  patient  has  a  good  set  of  teeth 
to  fasten  the  splint  to,  the  method  is  probably  the  most  perfect 
known.  It  is  neat,  efficient  and  allows  easy  cleansing  of  the  mouth 
together  with  free  motion  of  the  jaw  during  the  after-treatment. 
There  are  no  bandages  about  the  head  and  no  clamps  beneath  the 
chin  so  that  the  patient  is  able  to  go  about  in  public  without  being 
an  object  of  curiosity.  If  wounds  of  the  face  accompany  the 
fracture  they  may  be  treated  without  disturbing  the  fixation  of 
the  fragments. 

5.  Wiring  the  lower  jaw  to  the  tipper. — This  is  a  method  which 
has  the  disadvantage  of  not  allowing  motion  of  the  mandible  dur- 
ing treatment  and  renders  feeding  and  cleansing  of  the  mouth 
more  difficult.  On  the  other  hand  it  secures  good  occlusion  and 
does  not  require  any  special,  complicated  apparatus  or  laboratory 
technique  for  its  employment.  The  question  of  apparatus  or  the 
assistance  of  a  dentist  is  not  a  hindrance  in  large  cities  but  when 


:5H6  FKACTIKES    AM)    DISLOCATIONS 

the  surgeon  is  called  upon  to  treat  the  condition  without  these 
aids  he  will  find  that  \viriii>i  together  of  the  jaws,  if  i)roi)erly  car- 
ried out  anti  due  cari'  exercised  in  tin'  subsc(|nent  cleansing  of  the 
mouth,  will  ]ii('ft  the  i-f(|uiriMiiriits  in  most  c'lsrs  and  is  productive 
of  the  very  best  results. 

The  danger  of  vomiting  during  the  time  the  jaws  are  wired 
together  should  be  constantly  borne  in  mind,  and  the  patient  nuist 
be  provided  with  wii-e  cutting  pliers  so  that  the  jaws  may  be 
promi)tly  released  at  any  time,  h'or  the  same  reason  an  anes- 
thetic must  not  l)e  used  in  i'edueii\u'  the  I'raeture  if  this  method 
of  immobilizing  the  fi-agments  is  ein[)loyed. 

The  details  in  the  technique,  of  wiring  the  lower  to  the  upper 
jaw,  vary  witli  diffei-ent  surgeons  ])id  the  (>ssentials  are  the  same. 


Fig.  502. — Oliver's  method  of  wiring  the  lower  to  the  upper  jaw.  A.  shows  the 
loop  about  the  upper  centrals.  B.  shows  the  manner  in  which  the  loops  are  attached 
to  the   molars. 

Whatever  method  is  employed  we  may  expect  the  wire  to  stretch 
during  the  after-treatment  and  the  torsion  strength  of  the  wire  used 
must  be  sufficient  to  stand  the  additional  twisting  without  breaking. 
The  method  described  by  Oliver  is  probably  as  satisfactory  as  any 
and  has  the  advantage  of  preventing,  e(|ually  well,  both  lateral  and 
perpendicular  motion.  The  method  is  as  follows; — "for  purpose 
of  illustrating  the  method  let  us  suppose  a  case  with  simple  frac- 
ture slightly  transverse  through  socktit  (distally)  of  right  first 
bicuspid  and  mental  foramen,  slight  deformity,  articular  i)lane 
deranged,  long  anterior  fragment  drooping  somewhat  and  short 
posterior  fragment  drawn  slightly  upward  and  inward — the  typi- 
cal picture.  The  mouth  is  first  thoroughly  cleansed  with  hot  anti- 
septic wash  and  swabs,  the  location  and  extent  of  fracture 
determined  and  the  fragments  adjusted   and   articular   plane  re- 


J'HiACTUUIOS    OK    liOWKR    .(AW  ''AH 

stored.  Then  a  piece  of  soft  drawn  copper  wire,  about  four  inches 
long,  previously  annealed  and  sharpened  at  each  end,  is  inserted' 
from  without  inward  between  the  right  lateral  and  cuspid,  is 
pulled  through  about  half  its  length,  burnished  lingually  to  cuspid 
and  then  inserted  from  within  outward  l)etween  cuspid  and  first 
bicuspid,  pulled  through  buccally  again,  where  it  is  held.  The 
other  end  is  now  brought  back  and  inserted  at  the  latter  inter- 
proximal space,  pulled  through  taut,  burnished  lingually  to  first 
and  second  bicuspid,  carried  back  across  line  of  fracture,  inserted 
from  within  outward  between  first  molar  and  second  bicuspid, 
pulled  through  buccally  again,  brought  forward  taut  across  line 
of  fracture  and  twisted  with  remaining  ends  at  a  point  opposite 
an  interproximal  space.  The  adjustment  of  contour  and  articular 
plane  is  now  verified ;  after  which  the  ends  tightly  twisted,  bring- 
ing firm  traction  through  axis  of  each  fragment  across  line  of 
fracture  which  temporarily  will  hold  the  parts  in  their  exact  posi- 
tion. The  twisted  ends  are  clipped  off,  leaving  a  stub  about  an 
eighth  of  an  inch  long;  this  stub  is  turned  upward  and  inward, 
entering  the  interproximal  space  far  enough  to  prevent  it  from 
injuring  any  soft  tissues  with  which  it  may  come  in  contact.  Im- 
mobilization is  next  accomplished  by  wiring  lower  to  upper  teeth, 
while  occupying  normal  occlusion.  This  is  done  by  the  following 
original  method,  which  insures  against  the  possibility  of  any  mo- 
bility, either  lateral  or  perpendicular;  first  an  anchor  loop  is  made 
by  taking  a  six-inch  piece  of  annealed  soft  drawn  copper  wire,  20 
gauge  (B.  &  S.),  bending  it  in  the  middle  around  a  small-sized 
mandrel  about  one  thirty-second  of  an  inch  in  diameter,  and  twist- 
ing tight  by  one  full  turn  with  flat-nosed  pliers  (the  twist  may 
be  strengthened  by  "tacking"  together  with  a  small  bit  of  hard 
solder).  The  two  long  ends  are  now  straightened  out  and  placed 
parallel  to  one  another,  one  end  being  snipped  off  one-fourth  of 
an  inch  shorter  and  both  ends  pointed.  They  are  now  inserted 
from  without  inward,  between  the  tvvo  superior  central  incisors, 
pulled  through  taut  until  loop  rests,  horizontally,  firm  against  both 
teeth  at  the  mesocervical  border.  Each  end  is  now  carried  lat- 
erally from  median  line,  burnished,  respectively,  to  lingual  sur- 
face of  each  central,  and  inserted  from  within  outward  between 
its  respective  central  and  lateral,  pulled  through  firmly,  brought 
forward  to  median  line,  above  loop,  and  twisted  tightly  together. 


368  FRACTURES   AND   DISLOCATIONS 

clipping  off  and  turnint;  stub  into  interproximal  space  as  before 
noted.  Tills  forms  a  solid,  permanently  Hxi'd.  median  anchor  loop 
from  which  coiinler-ti-action  may  he  had  fi'om  each  lateral  luilf  of 
the  mandible  for  support  and  i)revention  of  lateral  mobility. 
Four  pieces  of  the  same  wire,  about  three  inches  long,  are  in  turn 
bent  around  the  mandrel  as  before  cited,  forming  the  loop  about 
one-third  distant  from  one  end  and  the  long  end  sharpened.  These 
lateral  anchor  loops  are  placed  around  solid  teeth,  one  on  each 
side,  usually  first  molars  or  second  bicuspids,  in  both  upper  and 
lower  jaws,  and  serve  as  anchorages  for  the  tiaetion  wares,  one 
for  each  side.  These  traction  wares  thi'tadcd  Ihrough  all  the 
loops  commencing  with  the  median,  then  the  supciior  latei-al,  then 
inferior  lateral  and  finally  twisted  wdth  ou1er  end  midway  between 
inferior  lateral  and  median  loop,  exert  a  firm  and  constant  pres- 
sure between  upper  and  lower  jaws  and  at  the  same  time  maintain 
counter-traction  laterally.  The  twist  is  elipi)ed  short  and  may  be 
turned  upward  under  upper  ti'cth.  The  lateral  loops  ai'e  posi- 
tioned by  inserting  long  ends  into  mesoproximal  spaces  of  the 
respective  teeth  selected,  pulled  through  taut  until  loop  rests  hori- 
zontally against  cervieoproximal  border,  then  carried  backward, 
burnished  to  lingual  surface,  inserted  from  wdthin  outward  at 
distoproximal  space,  pulled  through  firmly  and  twisted  to  outer 
end  as  near  the  latter  proximal  space  as  possible  in  order  that  the 
increased  size  of  twist,  being  too  large  to  pidl  back  through  space, 
wdll  prevent  the  anchorage  loop  turning  under  stress  of  subsequent 
traction  and  also  that  the  twist  may  be  clipped  off  and  turned 
into  the  space  as  above  shown.  The  traction  wires  are  about  seven 
inches  long,  of  same  material,  and  should  he  annealed  before  being 
used.  Care  should  be  exercised  to  keep  each  one  perfectly  straight 
between  loops  and  pulled  taut  in  passing  through  each  loop. 
When  properly  placed  there  will  be  a  triangular  geometrical  figure 
W'ith  its  first  ''stretch"  a  long  horizontal  line  from  median  to 
superior  lateral  loop,  a  short  perpendicular  line  from  the  supe- 
rior to  the  inferior  lateral  loop  and  a  long  slanting  diagonal  line 
from  inferior  lateral  to  median  loop,  in  which  the  twist  has  been 
made.  AYith  these  heavy  traction  wires  firmly  fastened  from  each 
side  of  the  jaw^  with  teeth  in  normal  contact,  there  is  little  lik'eli- 
hood  of  any  kind  of  motion  between  either  tlie  fragments  or  the 
jaws.  Should  a  wire  break  or  become  ineffective  from  being 
stretched,  a  very  firm  occipito-mental  bandage  is  applied  and  both 


FRACTURES   OP   LOWER    JAW  369 

traction  wires  cut  and  removed.     The  aiichoraf^e  loops  are  now 
tightened  and  new  traction  wires  applied  as  before."^ 

The  technique  of  simple  wiring  of  the  jaws  together  is  less 
complicated  than  Oliver's  method,  but  lacks  some  of  its  advan- 
tages.    It  is  accomplislied   by   passing   loops   about    the   teeth    as 


Fig.   503.  Fig.    504. 

Fig.  503. — Loops  of  wii-e  passed  about  teeth  of  lower  jaw  preparatory  to  wiring  the 
jaws  together. 

Fig.  504. — Loops  of  wire  passed  about  the  upper  teeth  corresponding  to  those  shown 
in  Fig.   502. 


Fig.   505.  Fig.   506. 

Fig.    505. — Two   points   of  fixation   in   wiring   the   maxillae  together. 
Fig.   506. — Opposite  side  in  same  ease  showing  line  of  fracture  and  two  additional 
points  of  fixation. 

shown  in  Fig.  503.  The  ends  are  twisted  together  to  obtain  a 
firm  hold  on  the  tooth  and  fastened  with  a  similar  pair  of  twisted 
ends  which  are  secured  to  a  tooth  in  the  opposite  arcade.  With 
this  method  it  may  be  necessary  to  replace  the  loops  about  the 
teeth  if  the  wires  break  by  twisting,  or  if  it  becomes  necessary  to 
cut  the  wires  in  case  of  vomiting.     Moreover  the  fixation  is  not 


1  R.  T.  Oliver,  D.D.S.,  Jour.  Amer.  Med.  Assn.,  Apr.  9,   1910. 


'670 


KKACTrUKS    AND    DISLOCATIONS 


(|uite  as  secure  as  Oliver's  method  and  it  is  not  possible  to  release 
the  jaws  as  quickly  in  case  of  emer^^cncN-. 

Angle's  bands  and  mre. — In  place  of  the  ant-lior  loops  described 
in  Oliver's  method  we  may  employ  Angle's  bands  such  as  shown  in 
Fig.  510.  They  are  ordinarily  used  in  orthodontia  but  serve  the 
pui-pose  in  fractures  very  nicely.  They  may  be  obtained  at  dental 
su|ii»l\  houses  and  the  knolis  for  securing  the  traction  wire  may  be 
atlaclu'd   to  the   band   at    any   point   desired  by  moans  of  solder. 


Fig.  507. — Simple  method  of  wiring:  the  upper  to  the  lower  teeth  in  fracture  of 
the  lower  jaw.  This  is  the  same  method  as  demonstrated  in  Figs.  50.3,  504,  505  and 
506.      Fragments    held    in    good    apposition    in    spite    of    dental    deficiencies. 

Loops  instead  of  knobs  are  sometimes  used  on  the  bands  and  are 
very  satisfactory.  Threaded  bars  and  jack-screws  are  made  to 
pass  from  an  Angle  band  on  one  of  the  lower  teeth  to  be  anchored 
on  a  band  placed  on  one  of  the  teeth  in  the  oi)posite  arcade,  but 
these  should  never  be  used  since  the  jaws  cannot  be  released 
quickly  with  ware  cutting  forceps  in  case  of  emergency.  The 
Angle  splint  will  be  considered  under  the  next  heading. 

6.  Securing  the  fragments  hy  means  of  iviring  the  teeth  of  the 
lotrcr   jaw. — Various    modifications    of   this    principle    have   been 


FRACTURES   OF   IjOWER    JAW  371 

devised  and  in  many  instances  the  metliod  is  tlioroujjihly  satis- 
factory. An  extremely  old  and  sometimes  efficient  method  is  that 
of  wiring  the  adjoining  teeth.  A  loop  of  heavy  wire  is  passed 
about  four  teeth  (two  on  either  side  of  the  fracture)  and  the  ends 
twisted  tightly  together,  cut  off  and  bent  inward  Ijetween  the 
teeth  so  as  not  to  injure  the  mucous  membrane.  It  is  usually 
difficult  to  get  this  wire  sufficiently  tight  by  twisting  a:;(l   when 


Fig.    5U8.  Fig.    5U9. 


Fig.   508. — Angle's    bands    and    bars    applied    to    fracture    of    the    mandible    at    the 
symphysis. 

Fig.   509. — Angle's    bands    and    bars    applied    to    fracture    of    the    mandible    between 
the  second  bicuspid  and  first  molar. 


Fig.    510.  Fig.    511. 

Fig.    510. — Angle's   bands   with  knobs   for   wiring  jaws   together. 

Fig.    511. — Same    case    as    shown    in    Fig.    510    showing    opposite    side    of    jaw    with 
points  of  fixation  on  either  side  of  fracture. 

such  is  the  case  a  racking  wire  is  passed  between  the  teeth  so  as 
to  include  both  arms  of  the  loop.  The  ends  of  this  wire  are 
twisted  tightly  together  and  in  so  doing  the  internal  arm  of 
the  loop  is  snugged  up  against  the  lingual  surface  of  the 
teeth.  The  wire  must  include  at  least  two  teeth  on  each  side 
of  the  fracture;  if  only  one  tooth  on  each  side  is  included  they 
will   almost   surely  loosen,   the   object   of   fixation  thus  being  de- 


372  FRACTURES   AND   DISLOCATIONS 

feated.  A  more  secure  method  of  wiring;  the  teeth  together  is 
described  by  Oliver  in  tlie  first  part  of  liis  procedure  (page  367). 
Any  form  of  \viring  must  be  closely  watched  and  tightened  to 
compensate  for  the  loosening  wliich  is  sun-  1o  lake  place.  For 
this  reason  silver  wire  is  not  as  satisfactory  as  some  other  forms 
on  account  of  the  likelihood  of  its  breaking-  when  much  twisting 
is  reciuired.  Bron/c-ahiniinmii  wire  of  large  caliber  or  ordinary 
electric  wire,  with  the  insuhition  removed,  may  be  used.  In  any 
event  the  wire  should  be  heavy  and  the  ends  pointed  to  facilitate 
its  passage  between  the  teetli.  If  it  is  desired  to  pass  wire  between 
the  teeth  where  there  is  not  sul^cient  space  an  opening  may  be 
made  slightly  below  the  gums  by  puncturing  with  a  sliarp  instru- 
ment; this  however  is  very  rarely  necessary.  Wiring  will  have  to 
be  varied  according  to  the  nature  and  disposition  of  the  teeth. 
When  there  is  nutch  tendency  toward  lateral  displacement  this 
method  should  not  be  employed;  it  is  particularly  inefficient  when 
the  line  of  fracture  through  the  body  is  oblique,  so  that  one  frag- 
ment tends  to  slip  past  the  other. 

Hammond's  ware  splint,  a  method  which  lias  been  followed  by 
good  results,  consists  of  a  heavy  iron  wire  encircling  all  the  teeth. 
One  continuous  wire  follows  the  lingual  and  buccal  surfaces  of  the 
lower  dental  arcade.  This  wire  should  be  heavy  enough  to  with- 
stand the  lateral  strain  and  after  fitting  it  to  the  teeth  it  is  better 
to  remove  it  and  solder  the  ends  together  rather  than  to  depend 
on  simple  twisting.  With  the  wire  in  place  about  the  lower 
denture  a  number  of  copper  racking  wires  of  lighter  material  are 
passed  between  the  lingual  and  buccal  arms  of  the  splint  and  the 
ends  twisted  to  secure  the  appliance  in  place.  Edmund's  forceps 
(Fig.  500)  may  be  used  to  force  the  heavy  wire  of  the  splint  more 
snugly  against  the  cervical  portions  of  the  teeth  and  to  facilitate 
tightening  the  racking  wires.  This  method  is  usually  not  secure 
enough  to  allow  motion  of  the  jaw  during  the  after-treatment  but 
should  be  used  in  conjunction  watli  some  method  of  fixing  the  jaws 
together. 

Angle's  splint  consists  of  bands  fastened  about  the  teeth  with 
a  threaded  bar  passing  between  them.  The  bands  are  similar 
to  those  used  in  wiring  the  jaws  together  but  have  heavy  tubes 
soldered  to  them  instead  of  the  knobs.  The  tubes  are  placed 
liorizontally  on  the  buccal  side  and  have  a  heavy  threaded  bar 
passing  through  them  from  one  side  of  the  fracture  to  the  other. 


FRACTURES   OF   LOWER    JAW  373 

When  the  nuts  are  placed  and  tightened  the  fragments  are  pulled 
together  and  held  in  firm  apposition.  The  splint  may  be  tightened 
by  passing  wire  from  band  to  band  on  the  lingual  aspect. 

Fracture  of  the  ramus  is  a  rare  condition  and  is  not,  as  a  rule, 
accompanied  by  much  displacement.  Some  form,  of  fixing  the  jaws 
together  will  afford  the  necessary  rest  for  the  ramus  and  will  be 
followed  by  good  results  in  most  cases.  When  much  deformity 
exists  open  incision  may  be  indicated  to  effect  reduction.  Wiring 
of  the  fragments  may  be  called  for  if  there  is  tendency  toward 
displacement  when  the  jaws  are  fixed.  Fracture  of  the  neck  of 
the  condyle,  like  fracture  of  the  ramus,  requires  fixation  of  the 
jaws,  and  may  require  operative  intervention  if  the  displacement  is 
pronounced.  In  operating  in  this  region  care  must  be  exercised 
to  avoid  injury  to  Stenson's  duct  and  the  facial  nerve  (see  Anat- 
omy, page  350).  Fracture  of  the  coronoid  is  extremely  rare  and 
will  probably  require  only  fixation  of  the  jaws  for  a  short  time. 

Operative  Treatment. — In  some  cases  it  may  seem  advisable  in 
meeting  the  requirements  of  the  case  in  hand  to  unite  the  frag- 
ments of  the  body  of  the  bone  by  direct  wiring  or  by  the  use  of  a 
small  Lane  plate.  This  is  done  through  an  incision  parallel  to 
and  slightly  below  the  lower  border  of  the  jaw.  In  making  this 
incision  care  should  be  taken  to  avoid  the  facial  artery  which 
crosses  the  external  surface  of  the  bone  in  an  upward  and  forward 
direction  at  the  antero-inferior  angle  of  the  masseter.  The  bone 
having  been  exposed,  holes  are  drilled  in  the  positions  of  greatest 
advantage  and  wire  passed,  twisted,  cut  off  and  turned  in.  In 
oblique  fractures  with  overriding  tendency  it  is  often  best  to  have 
both  arms  of  the  loop  passing  through  the  plane  of  fracture  in  the 
substance  of  the  bone.  In  transverse  fractures  a  single  loop  with 
one  arm  on  the  external  and  the  other  on  the  internal  surface  of 
the  bone  will  be  sufficient  to  secure  immobilization  if  the  serrated 
edges  of  the  fragments  are  well  engaged  and  the  wire  properly 
tightened. 

It  is  well  in  any  operative  procedure  about  the  jaw  to  refrain 
from  removing  loosened  teeth  and  spicules  of  bone  unless  entirely 
separated  from  the  surrounding  tissues,  since  the}^  usually  become 
solid  as  a  result  of  the  free  circulation  in  this  region.  In  some 
eases  of  fracture  of  the  jaw  we  have  actual  destruction  of  a  con- 
siderable portion  of  the  bone,  and  in  other  cases  we  have  loss  of 
osseous  tissue  through  infection  and  necrosis  and  in  such  instances 


r{74  FRACTURK8    AND    DISLOCATIONS 

it  is  ililificiilt  to  obtain  an  end  result  which  is  perfectly  satisfactory. 
AVhen  a  portion  of  the  bone  is  lost  good  occlusion  is  not  possible 
and  more  or  less  defoi-mity  is  bound  to  ensue  unless  some  method 
other  than  those  previously  described  is  resorted  to.  In  these 
eases  much  good  can  be  accomplished  by  means  ol"  bone  trans- 
l)lantation,  although  the  method  has  not  been  sufficiently  employed 
at  tile  pi-esent  time  to  state  definitely  what  its  limitations  may  be. 
However  transplantation  is  justified  and  indicated,  in  view  of  the 
unhappy  results  following  destruction  of  a  portion  of  the  jaw. 

The  bone  transplant  is  usually  taken  from  some  other  portion 
of  the  patient's  skeleton  and  placed  in  the  mandible  according 
to  the  principles  of  bone  transplantation  laid  down  in  Chapter 
LX. 

The  usual  rules  governing  union  in  fractures  do  not  hold  good 
about  the  face  since  the  free  circulation  is  capable  of  withstanding 
greater  insult  and  accomplishes  great,  rapid  and  extensive  repair. 
Cases  have  been  I'eported  in  recent  years  showing  excellent  results 
follow'ing  transplantation  of  bone  and  what  is  still  more  surpris- 
ing the  formation  of  new  bone  about  metallic  framework  previously 
built  to  fit  the  requirements  of  the  case.  This  metallic  frame- 
work has  even  been  successful  in  the  forming  of  a  new  condyle. 
The  transplant  is  most  easily  and  satisfactorily  obtained  from 
the  crest  of  the  tibia;  it  should  be  cut  to  accurately  fit  the  defi- 
ciency in  the  jaw.  Its  ends  must  be  placed  in  firm  apposition  with 
the  freshened,  living  ends  of  the  maxillary  fragments  and  should 
be  immobilized  by  wire  loops  or  plates.  The  transplant  must  not 
be  exposed  within  the  mouth  but  should  be  protected  at  least  by 
mucous  membrane.  Transplantation  should  not  be  performed  in 
the  presence  of  infection ;  it  is  essential  to  wait  until  all  dead  bone 
has  sloughed  out  or  been  removed  and  the  sinuses  healed  in,  before 
the  transplant  or  any  other  foreign  material  is  introduced.  In 
closing  the  incision  after  operation  on  the  jaw  a  subcutaneous 
suture  should  be  run,  gathering  in  considerable  tissue  between  the 
l)one  and  the  skin ;  by  this  means  we  will  avoid  the  unsightly  re- 
tracted scars  so  frequenth^  seen  following  operations  on  the  jaw. 

The  skin  is  best  closed  with  hoi'se-hair.  If  suppuration  follows 
the  operation  we  must  see  to  it  that  drainage  is  free  and  complete 
but  we  should  not  be  too  hasty  in  removing  foreign  materials, 
since  discharging  sinuses  in  this  region  frequently  close  of  them- 


PRACTIJRKK   OF    liOWKR    JAW  375 

selves  in  spite  of  the  presence  of  foreign  l)0(li(*s  such  hs  suture 
materials,  plates,  etc. 

After-Treatment.^The  after-treatment  of  fracture  of  the  jaw 
consists  in  keeping  the  mouth  clean  by  means  of  mild  antiseptic 
washes  and  seeing  to  it  that  the  mechanical  ai)pliance  in  use  is 
properly  accomplishing  its  purpose  of  immobilizing  the  fragments. 
When  a  method  is  employed  which  keeps  the  jaws  closed  the  pa- 
tient must  be  fed  with  liquids ;  an  aid  to  the  introduction  of  food 
will  be  found  in  passing  a  tube  between  the  cheek  and  the  teeth, 
the  end  passing  behind  the  last  molar.  Eggs  and  milk  will  form 
the  main  part  of  the  diet.  These  may  be  combined  in  different 
ways  and  various  flavoring  materials  used  to  prevent  the  patient 
tiring  of  them.     Soups  and  broths  will  add  variety. 

It  will  usually  not  be  necessary  to  keep  the  jaws  together  for  a 
period  longer  than  ten  days  or  two  weeks  so  that  the  inconvenience 
of  feeding  is  not  a  long  one.  Union  is  well  under  way  by  this 
time  but  the  mandible  will  not  be  in  condition  to  stand  any  con- 
siderable strain  until  two  months  or  more  have  elapsed  from  the 
time  of  fracture ;  the  patient  should  be  cautioned  in  this  regard. 

Prognosis. — The  usual  case  of  fracture  of  the  body  of  the  jaw 
should  be  followed  by  perfect  function  and  no  deformity.  Cases 
in  which  the  trauma  has  been  severe  and  in  which  there  have 
been  multiple  fractures  are  much  more  difficult  to  treat  and  ac- 
cordingly^ are  sometimes  followed  by  more  or  less  loss  of  function 
and  deformity.  Protracted  cases  and  those  in  which  infection  has 
occurred  may  be  followed  by  damage  to  the  articulation  and  in 
some  instances  ankylosis.  The  more  complications  the  case  pre- 
sents the  worse  the  prognosis. 


CHAPTER  XXIX. 

DISLOCATIONS  OF  THE  .lAW. 

Surgical  Anatomy. — The  teinporo-maxillary  articulation  pos- 
sesses niauy  anatomical  features  which  shoukl  he  understood  be- 
fore entering  upon  the  clinical  aspects  of  dislocations  of  this  joint. 
It  is  a  gingiymo-arthrodial  joint.  The  interarticular  fibro-car- 
tilage,  horizontally  placed,  divides  the  cavity  within  the  capsule 
into  two  distinct  articulations,  each  with  its  separate  and  complete 
synovial  membrane.  The  function  of  the  upper  articulation  is 
that  of  gliding,  which  is  brought  into  action  in  the  lateral  grind- 
ing motions  of  the  jaw,  and  when  the  chin  is  protruded.  The 
lower  articulation,  between  the  cartilage  and  the  condyle,  has  a 
purely  hinge-like  action,  used  in  raising  and  lowering  the  man- 
dible. The  peculiar  formations  of  the  condyle  and  glenoid  cavity 
are  difficult  to  appreciate  unless  one  examines  these  surfaces  on 
the  skull,  preferably  in  a  fresh  specimen.  The  nature  of  the 
articulation  permits  only  of  forward  dislocation  unless  fracture 
complicates  the  condition.  Backward,  outward  and  upward  dis- 
placements have  been  described  though  they  are  extremely  rare 
Backward  dislocation  may  occur  when  fracture  of  the  neck  of  the 
condyle  exists,  and  upward  displacements  have  been  reported  as 
the  result  of  the  condyle  having  been  driven  through  the  glenoid 
cavity. 

The  joint  has  practically  three  ligaments,  the  capsular,  internal 
lateral  and  stylo-maxillary.  The  external  lateral  ligament  is 
simply  a  thickening  in  the  outer  portion  of  the  capsule,  while  the 
interarticular  fibro-cartilage  lies  within  the  capsule  and  is  con- 
tinuous with  it.  The  internal  lateral  ligament  is  entirely  in- 
dependent of  the  capsule,  being  attached  above  to  the  spine  of  the 
sphenoid  and  below  to  the  lingula.  The  stylo-maxillary  ligament 
extends  from  the  tip  of  the  styloid  process  to  the  angle  of  the 
jaw.  The  anterior  portion  of  the  capsule  is  the  only  ligament 
limiting  anterior  displacement  of  the  condyle  after  it  has  ridden 
over  the  eminentia  articularis. 

376 


DISLOCATIONS   OF    JAW  377 

Dislocation  of  the  jaw  is  almost  always  the  result  of  rmiseular 
action,  although  violence  has  been  known  to  have  produced  the 
condition.  A  blow  on  the  chin,  or  a  forward  blow  on  the  angle  of 
the  jaw  while  the  month  is  open  is  known  to  have  caused  the 
luxation.  It  has  occurred  in  yawning,  talking,  singing,  coughing 
and  vomiting.  Overaction  of  the  external  pterygoid  while  the  jaw 
is  depressed  is  responsible  for  the  luxation.  When  the  condyle 
has  been  displaced  far  enough  forward  to  become  engaged  in 
front  of  the  prominence  of  the  eminentia  articularis,  it  is  held  in 
displacement  by  spasm  of  the  internal  pterygoid,  masseter  and  the 
posterior  fibres  of  the  temporal. 

Etiology. — This  dislocation  occurs  more  commonly  in  middle 
aged  persons  and  is  more  frequently  seen  in  women  than  in  men. 
It  is  usually  the  result  of  muscular  action  and  rarely  caused  by 
violence. 

Sjnnptoms. — In  the  usual  bilateral  dislocation  the  mouth  is 
opened  widely,  and  the  entire  jaw  displaced  forward.  Saliva 
drools  from  the  mouth.  Articulation  is  impossible,  and  when  the 
patient  attempts  to  talk  he  is  almost  unintelligible.  Considerable 
pain  is  experienced  during  the  time  the  condylar  processes  are 
displaced.  In  the  unilateral  dislocation  the  mouth  is  open,  chin 
protruded  and  displaced  to  the  opposite  side,  which  gives  the  face 
a  peculiar  twisted  appearance.  The  displaced  condyle  may  be 
felt  below  the  zygomatic  arch  and  a  depression  exists  just  in  front 
of  the  ear  indicating  the  empty  glenoid  cavity. 

Treatment. — Reduction  is  accomplished  by  forcing  the  rami  of 
the  jaw  downward  and  backward  as  the  body  of  the  bone  is  raised. 
The  thumbs  are  protected  by  a  towel,  or  heavy  bandages,  intro- 
duced into  the  mouth  and  carried  as  far  back  as  the  last  molars 
on  either  side,  the  opposing  fingers  then  secure  the  lower  border 
of  the  body  of  the  bone.  Downward  and  backward  pressure  is 
then  made  by  the  thumbs,  forcing  the  condyles  over  the  articular 
eminences  as  the  body  of  the  bone  is  raised.  The  thumbs  should 
be  removed  before  the  molars  come  together.  The  spasm  of  the 
muscles  previously  referred  to  sometimes  offers  a  most  serious  ob- 
struction to  reduction  even  to  the  extent  of  necessitating  an  anes- 
thetic. It  is  surprising  with  what  facility  reduction  may  be  ac- 
complished with  the  muscles  relaxed  in  cases  in  which  the  jaw 
seemed  immovable  in  its  displacement  before  an  anesthetic  was 
given.     It  is  extremely  rare  to  find  a  case  in  which  reduction  can- 


378  FRACTURES    AND   DISLOCATIONS 

not  l)c  ;ici-()iiiiilislu'(l  uiidi'i-  anesthesia.  If  the  displaeenieiit  has 
existed  for  some  months  the  formation  of  adhesions  about  the 
condyle  and  changes  in  the  glenoid  cavity  may  necessitate  open 
incision  to  effect  reduction.  If  necessary  the  condyle  may  be 
rescclctl  with  a  view  to  the  formation  of  a  new  joint. 

After-Treatment. — The  jaw  should  be  fi.xed  for  a  i)criod  of  two 
weeks  followiiii;'  the  accident.  This  is  readily  accoini)lishe(l  by 
means  of  a  four-tailed  or  Barton  bandage.  The  jjatient  should 
be  cautioned  not  to  open  the  mouth  too  far  for  at  least  another 
month  following  the  removal  of  dressings.  When  dislocation  of 
the  jaw  has  once  taken  place  it  is  likely  to  occur  again,  and  unless 
the  patient  is  apprised  of  this  fact  he  may  feel  that  the  treat- 
ment was  not  successful  if  luxation  recurs  even  at  a  remote 
period. 

Prognosis. — Keduction  is  usually  accomplished  without  difficulty 
in  recent  cases.  Restoration  of  function  is  ])erfect  with  the  ex- 
ception of  a  tendency  to  habitual  luxation  which  exists  in  all 
eases. 


CHAPTER  XXX. 

SCALP  WOUNDS. 

Wounding  of  the  scalp  is  such  a  frequent  and  important  compli- 
cation of  fracture  of  the  skull,  that  the  management  of  these 
wounds  is  best  considered  before  entering  upon  the  subject  of 
injury  to  the  skull  and  brain.  Fracture  of  the  vault  of  the  skull 
is  usually  accompanied  by  wounding  of  the  scalp  or,  in  other 
words,  the  fracture  is  compound;  and  the  successful  treatment  of 
the  wound  will  often  determine  whether  or  not  infection  will 
follow  the  injury,  and  hence  is  of  the  greatest  importance. 

Surgical  Anatomy  of  the  Scalp. — The  scalp  is  composed  of  five 
layers : 

1.  The  skin. 

2.  The  subcutaneous  layer  of  fat. 

3.  The  oceipito-frontalis  muscle  and  its  aponeurosis. 

4.  The  subaponeurotic  connective  tissue. 

5.  The  pericranium. 

These  laj^ers  individually  and  collectively  are  of  considerable 
surgical  importance  and  should  be  understood  when  treating 
wounds  of  this  region.  The  skin  of  the  scalp,  the  toughest  and 
thickest  in  the  entire  body,  is  supplied  with  immerous  hair  fol- 
licles and  sebaceous  glands.  The  subcutaneous  layer  of  fat  has 
bundles  of  fibrous  tissue  passing  through  it  in  all  directions,  and, 
together  with  the  skin,  is  firmly  adherent  to  the  aponeurosis  of 
the  oceipito-frontalis  which  lies  directly  below  it.  The  hair  fol- 
licles of  the  skin  extend  down  into  the  subcutaneous  tissue,  and  in 
gaping  wounds  the  bulbous  ends  of  the  follicles  may  be  seen  by 
everting  the  edges.  The  aponeurotic  layer  or  galea  is  composed 
anteriorly,  of  the  frontalis  muscle,  which  is  inserted  into  the  skin, 
posteriorly,  of  the  occipitalis  muscle,  which  arises  from  the  superior 
curved  line  of  the  occipital  bone,  and  the  aponeurotic  tissue  or 
tendon  which  extends  between  these  two  muscles  and  divides  the 
scalp    surgically    into    two    layers; — the    superficial    and    deep. 

379 


380  FRACrrRRS  axd  dist^ocattons 

AVoniuls  whicli  divide  the  aponeiirotic  layci-  will  fjape,  while 
wounds  which  penetrate  only  to  the  galea  will  i)res('iit  approxi- 
mated edges.  Transverse  wonnds  dividing  the  galea  usii;illy  gape 
more  widely  than  wounds  of  the  same  deptli  running  in  an  antero- 
posterior direction.  TIk^  three  superficial  layers  just  named  are 
loosely  connected  with  the  deeper  structures  by  means  of  an  areo- 
lar tissue  which  allows  free  motion  of  the  upper  layers  over  the 
skull.  The  layer  of  subaponeurotic  connective  tissue  is  of  the 
greatest  surgical  importance  since  infections  in  this  loose  areolar 
tissue,  following  the  lines  of  least  resistance,  may  spread,  and  if 
not  prom])tly  and  freely  drained  the  entire  calvarium  may  he 
covered  hy  the  infection  and  the  scalp  "floated"  with  pus.  The 
pericranium  is  the  deepest  layer,  covers  the  calvarium  .ind  acts 
as  a  modified  periosteum.  It  differs  from  periosteum  in  other 
regions  in  the  following  respects :  the  pericranium  does  not  re-form 
bone  following  loss  of  osseus  tissue  to  the  extent  observed  in  peri- 
osteum elsewhere;  the  circulation  is  less  free;  and  it  may  be 
stripped  from  the  bone  without  causing  any  serious  disturbance  in 
the  nutrition  of  the  denuded  osseous  tissue.  Where  the  pericran- 
ium crosses  the  sutures  it  is  intimately  connected  with  the  inter- 
sutural  connective  tissue,  though  in  other  portions  of  the  skull 
it  may  be  readily  stripped  from  tlie  bone.  The  scalp  as  a  whole, 
together  with  the  hair,  affords  an  excellent  protection  to  the  skull 
and  is  richly  supplied  with  blood  vessels.  The  main  portion  of  the 
circulation  of  the  scalp  runs  in  the  subcutaneous  connective  tis- 
sue and  in  the  skin  itself,  and  its  richness  accounts  for  the  re- 
markable reparative  properties  of  the  scalp,  which  are  not  equalled 
elsewhere  in  the  skin  of  the  body  except  the  face.  Tlie  amount  of 
fibrous  tissue  present  in  the  layer  in  which  the  blood  vessels  run 
accounts  for  the  profuse  and  prolonged  hemorrhage  so  common  in 
scalp  wounds.  This  fibrous  tissue  prevents  the  vessels  from  clos- 
ing as  they  do  elsewhere  following  injury,  and  explains  the  diffi- 
culty so  frequently  experienced  in  catching  and  ligating  vessels 
in  the  scalp.  The  mobility  of  the  scalp  will  often  save  the  parts 
from  wounding  by  allowing  them  to  give  before  the  vulnerant 
body. 

Vessels  of  the  Scalp. — Tn  the  frontal  region  we  have  the  frontal 
branch  of  the  ophthalmic  artery  which  emerges  from  the  inner 
angle  of  the  orbit  and  anastomoses  with  its  fellow  of  the  opposite 
side  and  with  the  sui)raorbital  artery.     The  supraorbital  artery  is 


SCALP    WOUNDS  381 

a  branch  of  the  ophthalmic,  of  larger  size  than  the  frontal.  It 
emerges  from  the  orbit  through  the  supraorbital  notch  at  the 
junction  of  the  inner  and  middle  thirds  of  the  sui)raorbitMl  ridge, 
and  divides  into  superficial  and  deep  branches  anastomosing  with 
the  frontal  and  anterior  branch  of  the  superficial  temporal  artery. 
The  side  of  the  scalp  is  supplied  by  the  superficial  temporal,  a 
branch  of  the  external  carotid  artery,  which  may  be  palpated  as 
it  ascends  just  in  front  of  the  auricle.  This  artery  divides  into 
an  anterior  and  posterior  branch  and  anastomoses  with  the  deep 
temporal  arteries;  the  anterior  branch  of  the  superficial  temporal 
anastomoses  with  the  supraorbital,  and  the  posterior  branch 
anastomoses  with  the  posterior  auricular  and  occipital  arteries. 
The  deep  temporal  arteries  are  two  branches  of  the  internal  maxil- 
lary; they  supply  the  temporal  fossa,  anastomose  with  each  other 
and  with  the  superficial  temporal  and  lachrymal  arteries.  .  The 
occipital  and  posterior  auricular  arteries, — branches  of  the  ex- 
ternal carotid, — supply  the  posterior  portion  of  the  scalp  as  far 
forward  as  the  ears,  and  anastomose  with  each  other  and  the 
posterior  branch  of  the  superficial  temporal  artery.  The  occipital 
artery  passes  onto  the  scalp  at  a  point  about  midway  between  the 
inion  and  the  external  auditory  meatus  and  in  this  region  is  more 
or  less  exposed  to  injury ;  when  opened  it  may  give  rise  to  profuse 
hemorrhage.  It  may  be  temporarily  controlled  by  compressing 
it  against  the  skull  on  the  proximal  side  of  the  wound.  All  of 
the  arteries  of  the  scalp  may  be  temporarily  controlled  by  the 
application  of  an  elastic  tourniquet  about  the  head,  which  is  kept 
in  place  until  the  main  branches  are  secured  with  ligature.  The 
arteries  most  likely  to  cause  free  hemorrhage  are  the  occipital  and 
superficial  temporal,  either  of  which  may  be  controlled  by  digital 
pressure  against  the  skull  below  the  wound.  The  anastomosis  be- 
tween the  above  named  arteries  is  very  free,  and  the  size  of  the 
vessels  is  large  for  the  region  supplied;  the  result  is  that  the 
blood  supply  to  the  scalp  is  great,  and  the  vitality  of  the  tissues 
correspondingly  high. 

The  veins  of  the  scalp  correspond  to  the  arteries  just  named, 
though  there  are  some  differences  which  are  worthy  of  surgical 
note.  The  supraorbital  vein  anastomoses  with  the  cavernous  sinus 
by  means  of  the  angular  vein  near  the  inner  angle  of  the  eye,  and 
thus  infection  in  the  region  of  the  forehead  may  be  drained  into 
the  cavernous  sinus  as  well  as  into  the  facial  vein,  which  is  the 


382  FR\("rrRES  and  dtpt.ocations 

continuation  of  llif  suprnorhital.  t'orres{)ondin<2,-  to  the  arterial 
arrangement  in  this  i-fizioii.  The  supei'ioi'  loniiitiidiiial  sinus  re- 
ceives blood  I'roiii  outside  the  skull  liy  lucaiis  ol'  tlic  vein  which 
passes  throu^ii  the  parietal  foramen,  .ind  in  like  manner  connection 
is  established  between  the  scalp  and  lalerai  sinuses  through  the 
mastoid  and  jiosterior  condyloid  veins.  These  anastomoses  are  of 
importance  in  showing  tlie  way  in  which  infection  may  pass  fi-om 
tlie  outei-  surface  of  tlie  skull  to  tlie  intracranial  sinuses. 

TIk  luiiiplnilic  f(ss(ls  fonn  a  tVee  anastomosis  in  the  scalp  I'roni 
whicli  are  derived  the  main  trunks  which  follow  the  course  of  the 
arteries.  The  anterior  portion  of  the  scalp  is  drained  into  the 
•submaxillary  glands;  the  temporal  I'cgion  and  that  portion  of  the 
scalp  above  it  is  drained  into  the  superficial  and  deep  parotid  lym- 
phatic glands.  That  i)ortion  of  the  scalp  lying  behind  a  vertical 
line  connecting  the  two  external  auditory  meati  is  drained  into  the 
occipital   and   ])osterior   auricular   glands. 

The  nerves  of  the  scalp  may  be  divided  into  sensory  and  motor. 
The  sensory  nerves  are  of  cranial  and  cervical  origin.  The  an- 
terior portion  of  the  scalp  is  supplied  by  branches  of  the  fifth 
cranial  nerve  and  extends  upward  to  about  the  middle  of  the 
vertex.  The  posterior  portion  of  the  scalp  is  supplied  by  branches 
of  the  upper  cervical  nerves.  The  sensory  nerves  may  cause  con- 
siderable pain  lasting  over  a  long  period  of  time  if  they  become 
caught  in  scar  tissue  and  may  necessitate  oi)eration  to  afford  the 
patient  relief. 

All  the  muscles  of  the  scalp  are  supplied  by  the  facial  nerve ; 
the  occipitalis  muscle  sometimes  receives  additional  filaments  from 
the  occipitalis  minor  nerve.  The  upper  branch  of  the  "pes  an- 
serinis, "  supplying  the  frontalis,  is  the  most  frequently  injured 
motor  nerve  in  the  scalp.  Inability  of  the  patient  to  wrinkle  the 
corresponding  half  of  the  forehead  should  lead  to  a  search  for  the 
divided  ends  of  this  nerve  before  a  scalp  wound  of  this  region  is 
closed. 

Pathology  and  Symptoms. — AVounds  of  the  scalp  may  be  classi- 
fied as  incised,  punctured,  lacerated  and  contused ;  the  nature  of 
the  wound  depending  on  the  character  of  the  vulnerant  body  and 
the  degree  of  trauma  causing  the  injury.  In  addition  we  may  have 
a  simple  contusion  without  an  opening  or  wound  in  the  scalp,  and 
although  it  cannot  properly  be  considered  as  a  scalp  wound  yet 
its  importance  requires  consideration  under  this  heading.     Simple 


SCALP    WOUNDS  383 

contusion  of  the  scalp  is  common  and  may  lead  to  collections  of 
blood  or  serum  in  any  of  the  various  layers  of  the  scalp.  When 
the  collection  of  blood  is  in  the  movable  layer  of  the  scalp  (i.e., 
above  the  galea)  it  will  be  found  to  be  freely  movable  with  the 
skin  and  quite  circumscribed.  When  the  fluid  is  below  the  galea 
it  is  not  movable,  is  much  more  diffused  and  may  present  a  cir- 
cumference of  induration  which,  when  palpated  in  connection  witli 
the  softened  centre  of  the  effusion,  gives  one  the  sensation  of  a 
depressed  fracture.  Continued  digital  pressure  on  this  margin 
of  induration  will  usually  cause  the  fluids  to  be  displaced  suffi- 
ciently to  differentiate,  but  if  this  is  not  satisfactory  a  needle  may 
be  used  or  the  parts  incised. 

Effusions  below  the  epicranium  are  rare  except  in  infancy ;  when 
they  do  occur  they  will  be  found  limited  to  one  cranial  bone  of 
the  vault,  since  the  fusion  of  the  epicranium  with  the  intersutural 
fibrous  tissue  stays  the  further  spread  of  the  blood.  Birtli  trauma 
and  the  free  vascular  connection  between  the  epicranium  and  the 
skull  in  infancy  accounts  for  the  comparative  frequency  of  such 
effusions    (cephalhematomata)    during  that  period. 

The  incised  wound,  strictly  speaking,  is  caused  by  some  ob.ject 
with  a  sharp  or  cutting  edge,  yet  there  is  a  distinction  which  must 
be  made  between  a  truly  incised  wound  and  an  apparently  incised 
wound  which  has  been  produced  by  some  blunt  instrument,  such 
as  a  club.  A  scalp  wound  produced  by  a  club  may,  to  the  inex- 
perienced, have  all  the  characteristic  appearances  of  an  incision, 
though  on  closer  inspection  it  will  be  found  to  have  a  slightly 
ragged  and  contused  edge  and  the  underlying  structures  will  not 
be  found  divided  as  by  a  knife.  The  cause  of  wounds  has  an  im- 
portant medico-legal  significance,  and  when  the  attending  surgeon 
is  called  upon  to  give  testimony  he  should  be  aware  of  the  close 
similarity  existing  between  true  incised  wounds  and  those  made  by 
a  dull  instrument.  The  mechanism  of  the  pseudo-ineised  wound 
has  been  likened  to  the  splitting  of  a  kid  glove,  struck  with  a  cane 
while  the  leather  is  stretched  across  the  knuckle. 

The  punctured  variety  of  wound  in  the  scalp  is  produced  by 
pointed  instruments,  and  the  fact  that  the  depths  of  the  wound  are 
not  easily  inspected  without  exploratory  incision  accounts  for  the 
overlooking  of  injury  to  the  underlying  skull  and  brain  in  many 
instances.  It  should  be  remembered  that  the  punctured  wound 
has  the  traumatic  energy  distributed  over  a  very  small  area  and 


384  FRACTURES    AXD    DTST.OC ATTOXS 

is  tlierefore  more  likely  to  do  damage  to  the  underlyintj  structures. 

Laceration-  of  the  scalp  inav  exist  in  all  degrees,  t'l'oin  a  slight 
tear  to  a  complete  avulsion.  'I'lie  average  scalp  wound  shows  some 
degree  of  laceration  and  nioi'e  or  less  contusion,  so  tliat  foi-  ju-ac- 
tical  purposes  wounds  ])r('S('nting  these  features  are  best  considered 
under  one  heading.  I'lie  tissues  of  the  scalp  nuiy  be  torn  and 
bruised  in  various  ways,  and  the  degree  of  injury  ranges  from  the 
most  serious  to  the  most  trivial;  the  important  question  in  each 
case — so  far  as  the  scalp  itself  is  concerned — is,  wlial  portion  of 
tlie  tissues  injured  has  been  daiuagt'd  beyond  recovery?  This 
question  can  only  be  answered  by  a  careful  examination  of  the 
wound  and  an  estimation  of  the  circulation  remaining  in  the 
ragged,  mashed  and  torn  edges. 

Dirt,  cinders,  gravel,  broken  glass  and  various  other  materials 
may  be  ground  into  the  wound  and  the  surrounding  scalp,  and  if 
allowed  to  remain  will  act  as  foreign  infectious  bodies  within  the 
tissues.  Loose  hair  is  a  very  common  material  found  witliin  the 
wound  and  when  not  removed  is  almost  sure  to  be  followed  by 
suppuration. 

A  connnon  form  of  lacerated,  contused  scalp  wound  is  one  in 
which  the  l)low  causing  the  wound  has  resrdted  in  the  traumatic 
death  of  more  or  less  tissue,  which  will  ultimately  slough  out  if  not 
removed  at  the  time  of  operation.  When  the  edge  of  the  wound 
shows  slight  laceration  union  can  often  be  expected  even  if  the 
lacerated  edges  are  not  trimmed  away,  but  when  the  lacei-ation 
is  severe  and  the  edges  mashed,  we  may  look  for  more  or  less 
sloughing  if  this  tissue  is  not  removed,  regardless  of  the  presence 
or  absence  of  infection.  When  the  devitalized  tissue  is  extensive 
it  may  become  impossible  to  remove  it  and  approximate  the  edges. 
Inflammatory  reaction  is  much  more  pronounced  in  contused 
wounds  than  in  simple  incision  or  puncture.  A  type  of  injury 
frequently  seen  is  one  in  which  one  side  of  the  wound  has  been 
slid  and  separated  from  the  underlying  structures  as  the  result 
of  a  glancing  blow,  and  the  pocket  thus  formed  under  the  scalp 
often  contains  infectious  materials  which  have  been  forced  into 
the  wound  at  the  time  of  injury. 

Complications  and  Sequelae. — The  complications  may  be  grouped 
under  three  headings:  hemorrhage,  infections  and  conditions  ac- 
companying fracture  of  the  skull  and  brain  injury.  Late  compli- 
cations or  sequelae  are  painful  scar,  aneurism  of  the  scalp,  deform- 


SCALP   WOUNDS  385 

ing  contractures  of  >scar  tissue,  tumor  formation  in  thoi  scar  (kel- 
oids and  rarely  malignancy)  together  with  the  late  complifjitions 
following  brain  injury. 

Treatment. — The  treatment  of  these  wounds  will  depend  on  the 
conditions  present  in  each  individual  case  and  it  will  be  impos- 
sible to  formulate  the  routine  to  be  followed  in  all  instances.  A 
scalp  wound  may  be  present  without  any  evidence  of  injury  to 
either  skull  or  brain,  the  patient  not  having  suffered  the  slightest 
concussion,  while  on  the  other  hand  the  scalp  wound  may  be  a 
part  of  a  serious  condition  in  which  the  skull  is  fractured,  the 
brain  injured  and  the  patient  in  extremis.  These  extremes  to- 
gether with  the  intermediate  conditions  require  the  greatest  acu- 
men and  surgical  judgment  so  that  we  may  not  subject  the  patient 
to  unnecessary  operation  on  the  one  hand,  and  also  avoid  the  over- 
looking of  serious  complications  on  the  other.  There  are,  how- 
ever, some  general  principles  which  should  be  followed  in  the 
treatment  of  these  wounds,  though  the  relative  importance  of  each 
will  vary  in  different  cases.     They  are  as  follows : 

1.  Control  hemorrhage. 

2.  Prevent  infection  as  far  as  possible. 

3.  Avoid  the  overlooking  of  complications  especially  of  skull 

and  brain. 

4.  Close  the  wound  as  far  as  may  seem  advisable,  providing 

drainage  when  necessary. 

1.  Control  of  hemorrhage. — The  nature  and  amount  of  hemor- 
rhage will  depend  upon  the  character  of  the  wound  and  the 
vascular  structures  divided;  it  may  be  arterial  or  venous,  and  may 
consist  of  a  simple  oozing  or  an  active  spurting.  The  hemorrhage 
may  be  surprisingly  profuse,  when  some  of  the  main  arteries  of 
the  scalp  are  divided,  and  when  such  is  the  case  the  first  step  in 
treatment  must  be  the  control  of  this  bleeding.  "When  the  artery 
is  accessible  it  should  be  secured  with  hemostats  for  the  time  being, 
until  the  scalp  has  been  appropriately  cleaned;  if  the  hemorrhage 
consists  of  moderate  or  slight  oozing  it  may  be  neglected  during  the 
process  of  cleansing.  In  some  cases  it  may  become  necessary  to 
further  open  the  scalp  to  expose  the  bleeding  artery.  In  the  most 
profuse  hemorrhages  we  may  secure  temporary  hemostasis  by  pack- 
ing a  gauze  sponge  into  the  wound  and  making  firm  pressure  on 
it  with  the  hand.     In  the  case  of  hemorrhage  from  a  single  large 


386  FRACTURES    AND    DISLOCATIONS 

aitcry,  sucli  as  tlie  occipital  or  superficial  temporal,  we  may  com- 
press tlie  vessel  aizainst  the  skull  a  short  distance  to  the  proximal 
side  of  the  woiuul  pending  the  proper  securing  and  ligation  of 
the  bleeding  end.  In  extreme  cases  an  elastic  bandage  may  be 
used  to  encircle  the  head  so  that  it  passes  just  above  the  brows 
and  ears  and  in  this  manner  all  the  large  vessels  of  the  scalp  will 
be  compressed  against  the  skull. 

One  of  the  most  annoying  forms  of  hemorrhage  is  that  of  a 
IHM'sistent  oozing  which  continues  even  after  the  wound  has  been 
thoroughly  prepared  and  is  ready  for  the  sutures.  This  oozing 
may  come  from  the  edge  of  the  wound  proper  or  it  may  come  be- 
tween the  layers  of  the  scalp  in  cases  where  the  injury  has  been 
produced  by  a  glancing  blow  and  one  side  of  the  wound  has  been 
separated  from  the  underlying  tissues  by  "sliding."  Such  oozing 
is  not,  as  a  rule,  dangerous  in  itself  but  if  allowed  to  continue  after 
the  wound  has  been  closed,  Avill  result  in  the  formation  of  clots 
which  can  only  favor  subsequent  suppuration.  The  drier  the 
wound  when  closed  (other  things  being  equal)  the  more  reason  we 
have  to  anticipate  prompt  healing.  Oozing  ma}-  be  checked  in 
many  ways;  by  the  use  of  heat,  pressure,  styptics  and  sutures,  or  a 
combination  of  these.  A  method  which  will  in  most  instances  be 
found  all  that  is  required,  is  as  follows:  take  a  gauze  sponge  of 
appropriate  size  wrung  out  of  hot  salt  solution,  pack  it  into  the 
wound  and  make  firm  pressure  with  the  hand  from  tM^o  to  three 
minutes.  AVhen  the  sponge  is  removed  the  wound  surfaces  will 
be  found  dry  and  will  not  begin  to  bleed  again  unless  roughly 
handled.  This  procedure  is  best  carried  out  just  before  closing  the 
wound  when  the  manipulations  necessary  to  preparation  have  been 
completed.  A  solution  of  1 :2,000  of  adrenalin  may  be  used  to 
advantage  in  controlling  oozing  but  strong  chemical  styptics  should 
be  avoided  because  of  the  injury  they  do  to  an  already  trauma- 
tized tissue.  Oozing  from  the  edge  of  the  wound,  especially  of 
the  venous  type,  will  almost  invariably  stop  Avhen  the  sutures  are 
placed  and  tied.  After  the  wound  has  been  closed  it  is  advisable 
as  an  additional  precaution  to  make  pressure  from  one  to  two  min- 
utes to  prevent  the  continuation  of  oozing  and  to  express  any 
blood  which  may  have  collected  under  the  closed  scalp.  "When  it 
is  necessary  to  leave  buried  sutures  within  the  tissues  plain  cat- 
gut will  be  found  the  best.  If  hemorrhage  can  be  controlled 
without  the  use  of  buried  sutures  it  should  be  done. 


SCALP    WOUNDS 


387 


Fig.    512. — Ordinnry    scalp    wound   prepared   for    .suture.      Note    the    clean    shaving   of 
the    scalp. 


Fig.   513. — Sutures   taken   to   bring   the   margins    of   the   wound   together. 


Fig.    514. — Recurrent   bandage   of    the    injured   side   of    head   with    strips   of    adhesive 
applied  to  prevent  slipping. 


388  FRACTURES   AND   DISLOCATIONS 

2.  'IMic  iir(  n  iii ion  of  iiificiioii  is  to  be  aiH'oiiiplisluHl  aloiin'  lines 
siinilai-  to  tjiose  already  laid  down  under  the  "Treatment  of  Com- 
])ouml  Fractures"  (see  page  789).  Too  much  cannot  be  said  in 
condemnation  of  the  so-called  antiseptics,  such  as  bichlorid  of  mer- 
cury, which  invariably  do  more  harm  to  the  already  damaged  tis- 
sues than  they  do  to  the  germs  of  infection.  The  wound  should 
be  treated  by  attempting  to  remove  the  infection  which  has  already 
gained  entrance  and  not  by  killing  it  in  situ.  In  other  words  we 
should  endeavor  to  render  the  wound  aseptic  rather  than  anti- 
septic. It  is  of  course  practically  impossible  to  remove  all  infec- 
tion from  the  scalp,  yet  we  may  so  reduce  the  number  of  bacteria 
present  Avhen  the  wound  is  thoroughly  prepared  that  nature  is 
enabled  to  dispose  of  those  remaining  without  the  formation  of 
pus,  in  which  case  the  wound  is  said  to  heal  by  first  intention. 

Crushed  and  devitalized  tissue  has  no  resistance  and  can  serve 
no  i)urpose  within  the  wound  except  to  act  as  a  culture  medium 
for  infection  and  the  same  may  be  said  of  collections  of  dead 
blood.  The  indications  therefore  are  to  approximate  healthy  tis- 
sue and  to  avoid  the  extravasation  of  blood  and  serum  within  the 
wound.  Clinically  every  scalp  wound  must  be  considered  infected, 
yet  Ave  must  not  lose  sight  of  the  fact  that  additional  infection  and 
germs  of  different  strains  may  be  introduced  within  the  wound  by 
the  surgeon,  if  aseptic  regulations  are  not  observed.  The  first 
indication  in  the  treatment  of  scalp  wounds  (aside  from  the  con- 
trol of  severe  hemorrhage)  is  the  shaving  of  the  scalp  surrounding 
the  wound  and  the  cleansing  of  the  wound  itself.  Blood  and  dirt 
should  be  wiped  away  from  the  hair  which  is  then  clipped  away 
for  a  distance  of  two  to  two  and  a  half  inches  surrounding  the 
wound.  This  region  is  next  covered  with  lather  and  shaved,  care 
being  exercised  to  prevent  the  hair  and  dirt  from  entering  the 
wound.  After  this  has  been  accomplished  the  wound  is  irrigated 
with  salt  solution  and  the  unshaved  portions  of  the  scalp  dried, 
with  a  sterile  towel. 

When  the  surgical  surroundings  are  favorable  an  assistant 
should  perform  the  preparation  just  described  so  that  the  surgeon 
may  approach  the  prepared  scalp  with  clean  hands.  If,  however, 
the  surgeon  is  treating  the  wound  unassisted  he  should  re-sterilize 
his  hands  and  whatever  instruments  may  have  come  in  contact  with 
the  wound  during  preparation  in  order  that  the  subsequent  ma- 
nipulations may  be  rendered  sterile.     The  scalp  is  then  once  more 


SCALP  WOUNDS  389 

irrigated  in  and  about  tlie  wound  and  the  Kurgfon  is  ready  to 
explore  the  depths  of  the  wound  to  remove  infectious  materials 
such  as  hair,  felt,  gravel,  cinders,  etc.,  and  to  trim  away  devitalized 
tissue.  Isolated  hairs  show  a  strong  tendency  to  cling  to  the  inside 
of  the  wound  and  it  is  frequently  necessary  to  pick  them  out  in- 
dividually with  thumb-forceps  even  after  the  wound  has  been 
thoroughly  irrigated  and  is  supposedly  clean.  Tincture  of  iodine 
may  be  used  on  the  surface  of  the  scalp,  either  full  strength  or 
diluted,  but  is  best  kept  out  of  fresh  scalp  wounds.  Other  anti- 
septics within  the  wound  are  not  only  useless  but  harmful  and 
should  not  be  employed. 

3.  Detection  of  complications. — After  the  hemorrhage  has  been 
controlled  and  infection  prevented,  as  far  as  possible,  the  wound 
is  ready  for  the  sutures,  but  before  these  are  placed  the  surgeon 
should  satisfy  himself  that  no  symptoms  of  complications  have 
escaped  observation.  The  majority  of  scalp  wounds  may  be  ex- 
plored sufficiently  without  incision  to  satisfy  oneself  as  to  the  con- 
dition of  the  underlying  skull,  and  when  further  opening  of  the 
scalp  is  necessary  it  is  in  most  instances  easily  accomplished  under 
local  anesthesia.  The  local  examination  should  be  carried  to  a 
conclusion  satisfactory  to  the  surgeon  and  other  symptoms  of  frac- 
ture of  the  skull  noted  when  present.  The  ears  and  nose  should 
be  examined  for  hemorrhage  and  the  eyes  examined  as  to  their 
position  and  pupillary  reactions,  the  consciousness  of  the  patient 
noted  and  the  deep  reflexes  of  the  two  sides  compared.  In  other 
words,  if  fracture  of  the  skull  is  present  or  suspected  we  should 
examine  the  patient  for  all  the  symptoms  both  local  and  general 
which  are  known  to  occur  following  fracture  of  the  skull.  (See 
symptoms  of  "Fractures  of  the  Skull,"  page  411.) 

4.  Closure  of  the  luound. — After  the  preceding  three  steps  have 
been  carried  out  the  wound  should  be  closed  by  interrupted 
sutures,  preferably  of  silk  worm  gut,  extending  down  to  but  not 
penetrating  the  galea.  The  question  of  drainage  is  a  difficult  one 
to  settle  and  mistakes  are  sometimes  made  by  those  possessing  the 
greatest  experience.  The  greater  the  contusion  or  laceration  the 
greater  the  probability  that  the  wound  will  need  drainage.  If  the 
patient  can  be  kept  under  close  observation  following  the  closure 
of  the  wound  it  will  usually  be  unnecessary  to  provide  drainage, 
since  pus  can  be  detected  and  evacuated  with  little  difficulty  should 
it  form  within  the  wound.     If,  however,  the  circumstances  are  such 


390  FRACTURES   AND   DISLOCATIONS 

that  the  patient  is  not  soeu  for  a  tlay  or  two  following'  tlic  lirst 
treatment,  it  is  safei-  to  provide  drainage.  AVhen  the  drain  is  em- 
ployed it  should  be  iihu-ed  in  the  most  dependent  position  possible 
and  when  necessary  counter-openings  are  to  be  made  through  the 
scalp  and  drains  inserted.  A  ruliber  tube  about  the  size  of  a  thin 
lead  pencil,  sewed  into  tlie  lower  angle  of  the  wound  will  be  found 
a  satisfactory  form  of  drain.  The  wound  iua>'  then  be  covered 
witli  gauze  and  a  recurrent  baiulage  applied  to  the  head.  When 
the  wound  is  small  the  gauze  dressing  may  be  secured  to  the  shaven 
scalp  by  means  of  collodion. 

After-Treatment. — The  most  important  element  in  the  after- 
treatment  consists  of  the  detection  of  pus  within  the  wound ;  the 
case  should  therefore  be  kept  under  close  observation.  The  wound 
should  be  dressed  and  inspected  at  least  once  in  twenty-four  hours 
during  the  first  week  and  if  pus  is  suspected  a  fine  probe,  pre- 
viously sterilized,  in  a  flame,  may  be  passed  into  one  corner  of 
the  wound  and  the  content,  if  present,  evacuated.  If  pus  does 
develop  during  the  after-treatment,  it  should  be  thoroughly  evacu- 
ated and  openings  maintained  sufficiently  large  to  allow  free  egress 
of  the  septic  detritus.  An  infected  wound  should  be  freely  drained 
so  that  granulation  tissue  wall  fill  it  from  the  bottom.  The  aver- 
age clean  wound  will  be  solidly  healed  in  ten  days  and  the  stitches 
should  be  removed  on  the  eighth  or  ninth  day.  When  the  wound 
is  infected  the  healing  is  much  slower,  sometimes  lasting  for  weeks ; 
during  the  treatment  of  this  type  of  wound  granulations  may 
be  stimulated  by  the  use  of  balsam  of  Peru,  and  in  some  cases 
tincture  of  iodine  painted  over  a  foul  granulating  surface  will 
render  it  clean  and  active  in  the  course  of  a  few  days.  The  way 
in  which  iodine  acts  is  uncertain  yet  excellent  results  follow  its  use 
in  selected  cases.  The  application  of  iodine  to  granulation  tissue 
is  quite  different  from  its  use  on  a  fresh  wound,  where  no  special 
resistance  has  been  developed,  the  circulation  of  the  parts  is  not 
intact,  and  the  vitality  of  the  tissues  reduced  by  trauma.  When 
the  loss  of  tissue  is  such  that  the  scalp  cannot  be  closed  at  the 
first  treatment,  skin-grafting  should  be  resorted  to  if  the  defect 
is  one  which  cannot  be  filled  by  granulation  within  the  first  two 
or  three  weeks. 


CHAPTER  XXXI. 

FRACTURES  OF  THE  SKULL. 

The  skull  is  the  bony  protection  of  the  brain  and  when  this  pro- 
tective wall  is  injured  the  brain  is  likely  to  suffer,  at  least  in- 
directly. The  brain  may  suffer  injury  from  penetration  of  the 
vulnerant  body,  by  pressure  from  depressed  fragments,  by  ex- 
posure of  its  substance;  by  concussion,  contusion,  laceration,  in- 
fection and  degenerative  sequelee  such  as  cysts  and  abscesses. 

Fracture  of  the  skull  and  injuries  to  the  brain  are  distinctly 
different  subjects,  yet  the  frequency  with  which  they  are  asso- 
ciated makes  it  necessary  to  consider  them  under  one  heading.  If 
the  bone  lesion  were  all  that  we  had  to  confront  us  in  these  cases 
the  matter  would  be  simple,  but  with  the  addition  of  injury  to  the 
brain  it  becomes  one  of  the  most  complex  conditions  with  which 
we  have  to  deal.  Any,  all,  or  none  of  the  symptoms  to  be  enu- 
merated may  be  present  in  a.  given  case  at  the  time  of  examination ; 
accordingly  fracture  of  the  skull  may  be  the  easiest  or  the  most 
difficult  of  conditions  to  diagnosticate.  The  proper  treatment  will 
usually  depend  on  the  proper  diagnosis,  and  a  proper  diagnosis 
often'  calls  for  the  most  careful  observation  and  consideration  of 
every  symptom  present. 

Fracture  of  the  skull  may  be  divided  into  three  groups : 

1.  Those  in  which  recovery  would  take  place  without  treat- 

ment. 

2.  Immediately  fatal  cases,  and  those  who  live  but  a  few  hours 

(all  treatment  being  futile). 

3.  Those  whose  lives  can  be  saved  or  in  whom  serious  sequels 

may  be  averted  by  proper  treatment. 

The  last  group  is  the  one  to  which  our  attention  is  directed.  It 
is  however  no  simple  matter  to  determine  at  the  time  of  examina- 
tion to  which  group  a  given  case  may  belong.  The  unexpected 
is  more  common  in  head  injuries  than  in  other  fields  of  surgerj^; 
an   apparently  slight  injury  may  result  in   death   while   a   case 

391 


392  FRACTl'KKS   AXD    niSI,()CATIONS 

]>resontiiiji-  urave  syniptoins  may  rceovrr.  There  is  no  absolute 
means  of  avoidinji'  mistakes  in  the  diaunosis  and  ti-eatnient  of  tliese 
cases,  yet  careful  observation  comhined  with  sound  judgment, — 
the  i'ruil  of  study  and  cxitiTicncc. — will  I'cchirc  tlicsc  iiiislakes  to 
a    niiuiinnni. 

Classification. —  l^'fat-turcs  (,'1'  I  he  slcull  ha\'i'  been  \-ari()usly  classi- 
tied  and  the  terms  used  indicate  the  conditions  witliout  further 
definition.  We  have  fracture  of  the  vault,  fracture  of  the  base 
and  fractures  involving-  both  vault  and  ])ase.  Fractures  of  the 
base  may  be  clas.sified  according  to  the  fossa  involved.  There  are 
fissured  fractures,  depressed  fractures,  conuninuted  fractures,  etc., 
the  same  terms  being  used  as  are  applied  to  fractures  in  general. 

Surgical  Anatomy. — A  knowledge  of  the  anatomy  of  the  skull 
and  ])iain  is  essential  to  the  proper  interpretation  of  symptoms  and 
tilt'  adndnistration  of  treatment,  but  the  subject  is  so  extensive  that 
it  will  be  possible  to  consider  briefly  only  the  most  salient  features ; 
the  reader  being  referred  to  text-books  on  anatomy  for  more  de- 
tailed accounts. 

Bones  of  the  Skull. — Development. — The  bones  of  the  vault 
(tabular  portion  of  the  occipital,  parietals,  squamo-zygomatic  por- 
tions of  the  temporals,  and  the  frontal)  are  ossified  in  membrane 
from  centers  which  appear  at  about  the  end  of  the  second  fcetal 
month.  Ossification  beginning  in  the  center  of  a  quadrilateral 
bone  reaches  the  corners  last  and  accordingly  at  birth  we  find  the 
"fontanelles"  which  represent  the  unossified  por-tions  of  the  bones 
of  the  vault.  These  fontanelles  are  situated  at  the  four  angles  of 
the  two  parietal  bones  and  are  therefore  six  in  number.  The 
four  lateral  fontanelles  at  the  lower  angles  of  the  parietal  bones 
are  closed  a  short  time  after  birth ;  the  one  situated-  at  the  junc- 
tion of  the  sagittal  and  lambdoid  sutures  closes  within  the  first 
few  months  of  life ;  the  one  remaining,  situated  at  the  bregma,  con- 
tinues open  during  the  first  year.  Although  the  process  of  ossi- 
fication begins  earlier  in  the  vault  of  the  skull  than  in  the  base, 
nevertheless,  at  birth,  the  base  is  far  more  completely  ossified  than 
the  vault.  The  base  is  ossified  in  cartilage  as  is  the  rest  of  the 
skeleton.  Wormian  bones  occur  most  frequently  in  the  course 
of  the  lambdoid  suture  but  are  not  uncommonly  found  in  the 
fontanelles;  the  suture  surrounding  them  may  at  first  sight  be 
mistaken  for  a  linear  fracture  while  exploring  wounds  of  the  scalp. 
In  tlie  aged  the  frontal,  ]3arietals  and  occijntal  are  practically  one 


FRACTURES   OF    TIIP:   SKULL  393 

continuous  bone  due  to  the  ossification  of  the  sutures  between  th(nn ; 
the  basilar  process  is  continuous  with  the  body  of  the  sphenoid 
and  the  lesser  wings  of  the  sphenoid  are  continuous  with  the  orbital 
plates  of  the  frontal.  The  lambdoid  suture  meets  the  sagittal  suture 
at  a  point  about  two  and  a  half  inches  above  the  inion.  The  cen- 
ter of  the  anterior  fontanelle  (the  bregma)  is  at  a  point  about 
one-fourth  inch  anterior  to  a  vertical  line  connecting  the  external 
auditory  meati.  The  intersutural  fibrous  tissue  acts  as  a  linear 
shock  absorber  which  interrupts  or  reduces  vibrations  passing 
from  one  cranial  bone  to  another.  The  bones  of  the  skull  are  com- 
posed of  two  layers  of  compact  tissue  between  which  is  interposed 
a  layer  of  cancellous  tissue  known  as  the  diploe  or  diploic  layer. 
The  outer  layer  is  heavier,  stronger  and  less  brittle  than  the  inner. 
The  skull  is  by  no  means  of  a  uniform  thickness  throughout,  which 
fact  may  be  nicely  demonstrated  by  holding  the  base  of  the  skull 
up  against  the  light  and  noting  the  places  which  are  translucent 
and  those  which  are  opaque.  The  thin  regions  are  produced,  to 
some  extent,  by  obliteration  of  the  diploe,  and  these  areas  of  thin- 
ness and  thickness  are  of  importance  in  trephining  and  in  estimat- 
ing the  probability  of  penetration  in  a  given  region.  The  thin 
places  in  the  skull  are  the  orbital  plates  of  the  frontal  (supporting 
the  frontal  lobes),  the  squamous  portions  of  the  temporals  (in 
contact  with  the  spheno-temporal  lobes)  and  the  middle  of  the 
posterior  fossa  below  the  grooves  for  the  lateral  sinuses  (which 
accommodate  the  cerebellum).  At  any  of  these  places  a  well 
directed  blow  with  a  pen-knife  could  penetrate  the  skull  and  in- 
jure the  brain.  In  contrast  with  the  regions  of  thinness  there  are 
ridges  which  act  as  buttresses  and  serve  to  strengthen  the  skull. 
In  the  vault,  they  are  situated  as  follows:  the  torus  transversus  oc- 
cipitalis, a  thickening  in  the  bone  extending  laterally  from  the 
external  occipital  protuberance,  a  median  thickening  of  the  skull 
extending  from  the  glabella  to  the  foramen  magnum  and  corre- 
sponding to  the  course  of  the  superior  longitudinal  and  occipital 
sinus,  and  the  temporal  crests  ascending  from  the  external  angular 
processes  of  the  frontal  to  be  continued  into  the  temporal  ridges. 
In  the  base  we  have  the  ridges  which  divide  the  region  into  the 
three  fossa  and  notwithstanding  the  fact  that  they  are  composed 
largely  of  thin,  brittle  compact  tissue,  they  serve  nevertheless  to 
reenforce  this  part  of  the  skull.  They  are :  the  petrous  portion  of 
the  temporal  and  the  lesser  wing  of  the  sphenoid.     The  base  of 


394  FRACTURES   AND   DISLOCATIONS 

the  peti-ous  portion  of  the  temporal  is  applied  to  the  skull  in  a 
region  which  corresponds  to  the  mastoid  externally  and  accord- 
ingly this  part  is  comparatively  strong.  The  foramen  magnum 
is  also  surrounded  by  a  ridge  which  is  a  bifurcation  of  the  internal 
occipital  crest,  the  two  divisions  ascending  anteriorly  to  the  pos- 
terior clinoid  processes.  These  thickenings  in  the  skull  all  have 
more  or  less  tendency  to  modify  vibrations  and  hence,  to  stop  or 
divert  lines  of  fracture. 

The  foramina  in  the  base  of  the  skull  are  said  to  weaken  it, 
and  are  of  importance  since  the  study  of  their  positions  and  con- 
tents will  aid  in  determining  the  location  of  the  fracture.  In  the 
anterior  fossa  we  have  the  cribriform  plate  of  the  ethmoid,  the 
thinnest  and  weakest  place  in  the  floor  of  this  fossa.  It  transmits 
the  olfactory  and  nasal  nerves,  the  latter  passing  through  the  nasal 
slit.  In  the  middle  fossa  we  have  the  sphenoidal  fissure  which 
transmits  the  nerves  and  vessels  passing  to  the  orbit :  The  motor 
occuli,  abducens,  patheticus,  the  three  branches  (nasal,  lachrymal 
and  frontal)  of  the  ophthalmic  and  the  sympathetic  nerves  as  they 
pass  from  the  walls  of  the  cavernous  sinus  to  the  orbit.  These 
nerves  are  accompanied  by  three  vessels:  The  orbital  branch  of 
the  middle  meningeal  artery,  a  recurrent  branch  of  the  lachrymal 
artery  and  the  ophthalmic  vein.  The  foramen  rotuudum  and  ovale 
in  the  same  fossa  transmit  respectively  the  second  and  third 
branches  of  the  fifth  cranial  nerve  together  with  other  structures 
of  minor  importance.  The  middle  meningeal  artery  enters  the 
skull  through  the  foramen  spinosum  situated  in  the  tip  of  the 
great  wing  of  the  sphenoid.  Through  the  carotid  canal  we  have 
the  internal  carotid  artery  entering  the  cranial  cavity  accompanied 
by  the  carotid  plexus  of  the  sympathetic,  the  latter  being  con- 
tinued into  the  cavernous  plexus  when  it  reaches  the  side  of  the 
body  of  the  sphenoid.  The  foramina  in  the  posterior  fossa  are  the 
foramen  lacerum  posterius  or  jugular  foramen,  the  internal  audi- 
tory meatus,  the  two  condyloid  foramina  and  the  foramen  mag- 
num. The  jugular  foramen  transmits  the  glosso-pharyngeal,  pneu- 
mogastric,  and  spinal-accessory  nerves;  also  the  lateral  and  in- 
ferior petrosal  sinuses  and  a  small  artery.  The  inferior  petrosal 
and  lateral  sinuses  join  to  form  the  internal  jugular  vein  a  short 
distance  outside  the  skull.  The  anterior  condyloid  foramen  trans- 
mits the  twelfth  cranial  nerve  and  occasionally  an  artery,  the 
posterior   condyloid  foramen  transmits  a  vein   which   establishes 


FRACTURES   OF    THE   SKULL  395 

communication  between  the  lateral  sinus  and  the  deep  veins  of  the 
neck.  The  internal  auditory  meatus  transmits  the  facial,  the  audi- 
tory and  the  pars  intermedia  of  Wrisberg,  also  a  branch  from  the 
basilar  artery.  The  gustatory  fibres  of  the  seventh  join  the  nerve 
as  it  enters  the  internal  auditory  canal  and  leave  it  by  way  of  the 
chora  tympani. 

Membranes  of  the  Brain. — The  brain  as  it  lies  within  the  skull 
is  enclosed  within  three  membranes  which  conform  more  or  less 
closely  to  its  surface. 

The  dura,  the  most  superficial  of  the  three,  is  composed  of  tough 
inelastic  tissue  which  acts  as  the  internal  periosteum  of  the  skull 
and  is  richly  supplied  with  blood  vessels.  Most  of  the  nutrition 
of  the  bones  of  the  skull  is  derived  from  vessels  running  in  this 
membrane.  The  dura  is  composed  of  two  layers,  a  superficial  and 
a  deep.  The  superficial,  or  vascular,  layer  acts  as  the  endosteum 
while  the  deep  layer  is  lined  with  endothelium  on  its  deep  surface, 
and  dips  down  between  certain  portions  of  the  brain  to  form 
partitions  and  give  support.  The  dura  as  a  whole  is  more  firmly 
adherent  to  the  skull  in  childhood  and  in  old  age  than  it  is  in  mid- 
dle life ;  it  is  more  firmly  adherent  at  the  base  and  where  it  crosses 
the  sutures  than  elsewhere.  Sir  Chas.  Bell  has  demonstrated  the 
possibility  of  separating  the  dura  from  the  bone  without  opening 
the  skull;  ''Strike  the  skull  of  a  subject  with  a  heavy  mallet;  on 
dissecting  you  find  the  dura  mater  to  be  shaken  from  the  skull  at 
the  point  struck.  Eepeat  the  experiment  on  another  subject  and 
inject  the  head  minutely  with  size  injection,  and  you  will  find  a 
clot  of  injection  lying  betwixt  the  skull  and  the  dura  mater  at  the 
part  struck,  and  having  an  exact  resemblance  to  the  coagulum 
found  after  violent  blows  on  the  head." 

The  reduplications  of  the  dura  extending  into  the  cranial  cavity 
between  the  main  portions  of  the  brain  are  three  in  number;  be- 
tween the  hemispheres  of  the  cerebrum  we  have  the  falx  cerebri, 
between  the  lobes  of  the  cerebellum  we  have  the  falx  cerebelli,  and 
between  the  cerebellum  and  the  occipital  lobes  of  the  cerebrum 
we  have  the  tentorium  cerebelli.  The  venous  sinuses  run  between 
the  layers  of  the  dura  which  go  to  make  up  these  three  infoldings. 
The  tentorium,  like  other  portions  of  the  dura,  is  a  tough,  in- 
elastic membrane  and, — since  its  crescentic  margin  is  firmly  at- 
tached to  the  grooves  on  the  occipital  bone  (the  upper  edge  of  the 
petrous  portions  of  the  temporal  bones  and  the  posterior  clinoid 


396  FRACTURES    AXD    niST.OCATTONS 

processes), — it  is  more  or  less  liable  to  be  toi-n  when  the  cranium 
chano:es  form  durinpf  the  process  of  moulding,  as  it  passes  through 
the  birth  canal.  Intracranial  hemorrhage  may  then  take  place 
from  the  sinuses  running  between  its  layers.  The  falx  cerebri 
serves  to  prevent  the  hemispheres  of  the  cerebrum  from  jostling 
each  other  when  the  head  is  struck  or  moved  quickly,  and  the  falx 
cerebelli  serves  the  same  purpose  for  the  two  halves  of  the  cere- 
bellum. The  tentorium  cerebelli  sustains  the  weight  of  the  occipi- 
tal lobes  and  prevents  them  from  pressing  on  the  cerebellum. 

The  pia  mater  is  a  delicate  membrane  which  invests  the  surface 
of  the  brain,  contains  numerous  small  vessels  which  extend  per- 
pendicularly into  the  substance  of  the  cortex.  This  membrane  dips 
down  into  all  the  sulci,  following  the  surface  of  the  brain  in  every 
detail.  It  also  forms  the  velum  interpositum  and  the  choroid 
plexus. 

TJie  arachnoid  lies  between  the  dura  and  the  pia,  is  composed  of 
a  loose  areolar  tissue  and  divides  the  space  between  the  dura  and 
pia  into  the  subdural  and  the  subarachnoid  spaces.  The  arachnoid 
dips  into  some  of  tlie  larger  sulci,  but  resembles  the  dura  in  this 
respect  more  than  the  pia.  The  thickness  of  the  membrane  varies 
consideralily  in  diiferent  portions  of  the  brain.  On  the  cerebral 
hemispheres  it  is  tliin  and  delicate,  while  the  part  investing  the 
pons  is  heavy  and  much  less  vascular.  The  subarachnoid  space 
(between  the  arachnoid  and  pia)  is  quite  large  at  the  base  of  the 
brain  and  is  filled  with  cerebrospinal  fluid.  The  subarachnoid  and 
subdural  spaces  connect  with  the  ventricular  cavities  of  the  brain 
through  the  foramen  of  IMajendie  in  the  posterior  medullary  velum 
of  the  fourth  ventricle.  The  cerebrospinal  fluid  by  its  escape  into 
the  spinal  spaces  allows  a  certain  amount  of  displacement  of  the 
cranial  content. 

Vessels  of  the  Membranes. — The  vessels  running  in  the  dura 
are  often  partially  accommodated  by  grooves  on  the  inner  surface  of 
the  skull,  and  this  intimate  contact  between  bone  and  vessel  renders 
the  latter  quite  liable  to  injury  when  the  line  of  fracture  traverses 
these  bony  channels.  The  most  important  artery  in  the  dura  is 
the  middle  meningeal,  a  branch  of  the  first  portion  of  the  internal 
maxillary  artery;  it  gains  entrance  to  the  skull  through  the  fora- 
men spinosum  and  passes  outward  onto  the  internal  surface  of  the 
squamous  portion  of  the  temporal,  where  it  divides  into  an  ante- 
rior and  posterior  branch.     The  anterior  branch  passes  outward 


FRACTURES    OP    THE    KKtJLL.  397 

and  forward,  while  the  course  of  the  posterior  branch  is  outward 
and  backward.  E'oth  branches  are  continued  onto  the  inner  sur- 
face of  the  parietal  bone.  There  is  considerable  normal  variation 
in  the  courses  of  these  two  branches  after  they  reach  the  parietal 
bone,  and  we  have  no  possible  means  of  ascertaining  the  exact 
position  that  they  may  occupy  in  a  given  case.  The  anterior 
branch,  however,  will  usually  be  found  passing  upward  and 
slightly  backward  from  a  point  about  one  and  three  quarters  inches 
above  the  zygoma  and  one  and  a  half  inches  behind  the  external 
angular   process   of  the   frontal  bone.     The   course   of   the   artery 


Pig.  515. — Internal  surface  of  right  lialf  of  skull  showing  courses  of  middle  menin- 
geal artery  and  lateral  sinus.  In  this  case  the  posterior  branch  of  the  arterj-  is 
double  and  calls  attention  to  the  frequency  with  which  anomalies  occur  in  the  course 
and  distribution  of  this  vessel.  A  study  of  this  vessel  and  its  anomalies  will  point 
out  the  advantages  of  the  osteoplastic  method  of  opening  the  skull  as  compared  with 
trephining,    for    the    removal    of    clots. 

from  this  point  is  nearly  parallel  to  the  coronal  suture,  running 
from  one-half  to  three  quarters  of  an  inch  behind  it.  A  trephine 
opening  with  its  center  about  one  inch  above  the  external  auditory 
meatus  will  expose  the  posterior  branch  of  the  middle  meningeal. 
In  trephining  in  this  region  it  should  be  remembered  that  the  skull 
is  thin,  the  internal  surface  irregular  and  that  the  anterior  branch 
of  the  middle  meningeal  (especially  in  the  region  of  the  pterion) 
may  run  in  a  complete  bony  canal  instead  of  a  groove.  Kronlein's 
diagram  gives  the  three  most  frequent  sites  for  the  location  of 
clots  following  hemorrhage  from  this  artery.  The  diagnosis  of  the 
position  of  these  clots  is  often  difficult,  sometimes  impossible.     The 


398 


FRACTURES   AND   DISLOCATIONS 


most  satisfactory  method  has  been  found  in  the  osteo-plastic  flap 
Avhieh  exposes  enough  of  the  brain  to  satisfactorily  explore  its  sur- 
face without  missing  the  site  of  hemorrhage.  IMeningeal  hemor- 
rhage may  take  place  from  some  of  the  smaller  meningeal  arteries 
and  occupy  regions  in  the  frontal  or  occipital  lobes.  A  common 
form  of  meningeal  liemorrliage  is  tliat  arising  from  small  veins. 
A  linear  fracture  may  divide  small  veins,  and  the  resulting  hemor- 


Fig.   516. — View  of  right  half  of  interior  of  base  of  skull  showing  the  courses  of  the 
middle  meningeal  artery  and  lateral  sinus. 


rhage,  though  slow,  not  infrequently  forms  a  large  coagulum. 
In  this  form  of  hemorrhage  the  symptoms  are  slow  in  developing 
because  it  takes  a  number  of  hours  for  the  clot  to  assume  sufficient 
size  to  cause  disturbance.  In  addition  to  the  middle  meningeal 
artery,  there  are  also  other  meningeal  arteries  of  smaller  size. 
They  are  the  three  meningeals  from  the  ascending  pharyngeal : — 
the  anterior  meningeal  from  the  internal  carotid,  the  posterior 
from  the  vertebral,  and  the  small  meningeal  from  the  internal 


FRACTURES   OF   THE   SKULL  399 

maxillary.  These  arteries,  however,  are  all  of  small  size  and  rarely 
the  cause  of  hemorrhage. 

Intracranial  Sinuses. — The  most  common  site  of  meningeal 
hemorrhage,  after  the  middle  meningeal  artery,  is  the  lateral  sinus. 
The  walls  of  the  sinuses  are  formed  by  a  splitting  of  the  dura  and 
are  lined  by  an  endothelial  layer  which  is  continuous  with  the 
lining  membrane  of  the  veins.  Sinuses  may  be  the  site  of  throm- 
bosis and  suppuration  and  when  ruptured  result  in  intracranial 
hemorrhage ;  they  should  be  specially  avoided  when  trephining  the 
skull.  The  superior  longitudinal  sinus  corresponds  to  a  line 
drawn  from  the  glabella  to  the  inion.  A  line  drawn  from  the  inion 
to  a  point  one  and  a  half  inches  above  the  external  auditory  meatus 
will  correspond  to  the  highest  part  of  the  lateral  sinus  where  it 
crosses  the  lambdoid  suture.  The  lateral  sinus  then  curves  down- 
ward and  forward  running  on  the  internal  surface  of  the  mastoid 
portion  of  the  temporal.  It  is  joined  by  the  superior  petrosal 
sinus  at  the  posterior  end  of  the  upper  border  of  petrous  portion 
of  the  temporal  and  by  the  inferior  petrosal  sinus  just  below  the 
jugular  foramen  after  the  two  sinuses  have  passed  out  of  the  skull. 
The  two  cavernous  sinuses  situated  on  either  side  of  the  cella 
Turcica  drain  the  ophthalmic  vein,  anastomose  with  each  other 
through  tlie  circular  and  transverse  sinuses  and  are  themselves 
drained  into  the  lateral  sinuses  by  means  of  the  petrosal  sinuses. 
A  line  drawn  perpendicular  to  the  surface  of  the  bone  just  below 
the  inion,  if  projected  into  the  skull,  would  correspond  to  the 
course  of  the  straight  sinus.  The  straight  sinus  drains  the  veins 
of  Galen  and  the  inferior  longitudinal  sinus  which  runs  in  the 
lower  border  of  the  falx  cerebri.  The  blood  from  the  straight 
sinus  is  drained  by  one  of  the  lateral  sinuses  after  having  been 
emptied  into  torcular  Herophili.  The  occipital  is  formed  by  the 
two  marginal  sinuses  which  connect  with  the  sigmoid  portion  of 
the  lateral  sinus;  it  passes  upward  and  empties  into  the  lateral 
sinus,  the  straight  sinus  or  the  torcular  Herophili;  it  establishes 
connection  with  the  deep  veins  of  the  neck  through  the  foramen 
magnum.  The  origin,  course  and  exit  from  the  skull  of  the  twelve 
cranial  nerves  is  of  importance  in  diagnosis  but  the  reader  will  be 
referred,  for  this  detail,  to  text-books  on  the  subject. 

Lesions  of  different  portions  of  the  brain  will  give  different 
symptoms  according  to  the  function  of  the  region  injured.  We 
may  divide  local  injuries  of  the  brain  into  injuries  of  the  cortical 


400 


FRACTURES   AXD    DISLOCATIONS 


(H*iittM-s  aiul  tlieir  tracts,  and  iiijui-ies  of  tlie  haso.     For  practical 
])uri)os('s  we  may  divide  the  cortex  into  motor  areas,  sensory  areas, 

Kiu'.    318. 


Fig.    :519. 


Fis.    520. 


Fig.  517. — M.,  Midpoint  of  naso-inionic  line;  L.ti.,  Poirier's  line  and  corresponds 
to  Sylvian  fissure;  7.JV.,  Koeher's  equatorial  line  from'  nasion  to  inion;  A..B.,  German 
base-line  and  passe.s  through  inferior  edge  of  orbit  and  upper  border  of  external 
auditor}'   meatus. 

Fig.  518. — .v.,  Jj.K.  and  7. A',  same  as  in  Fig.  517.  A  line  drawn  forward  and 
downward  at  an  angle  of  60  from  median  plane  is  known  as  Koeher's  anterior 
meridian  and  lies  over  preoentral  convolution.  Koeher's  posterior  meridian  is  drawn 
downward    and   backward    60   from   the   median   plane. 

Fig.  519. — Dotted  areas  correspond  to  the  most  frequent  sites  of  meningeal  hemor- 
rhage. 

Fig.    520. — Cortical    centers. 

and  a  number  of  so-called  silent  areas.  The  cortex  of  the  brain 
is  composed  of  gray  matter  which  in  most  regions  is  disposed  in 
five  layers.     Axis-cylinders  from  the  cells  of  this  gray  matter  es- 


FRACTURES   OF    THE   SKULL  401 

tablish  commimieation  between  different  portions  of  the  cortex 
and  between  the  cortex  and  the  lower  centers  situated  in  the  base 
of  the  brain  and  in  the  cord.  The  function  of  the  cortex  of  the 
brain  is  to  register  memories  of  past  experiences.  Tinder  certain 
conditions  these  centers  are  stimulated  and  have  the  capacity  of 
reproducing  the  events  which  they  have  registered.  Thus  stimu- 
lation of  the  occipital  lobe  gives  us  the  memory  of  sights  seen, 
stimulation  of  the  temporo-sphenoidal  lobe  gives  us  the  memories 
of  sounds  heard,  stimulation  of  the  motor  area  gives  us  the  mem- 
ories of  acts  performed.  It  is  therefore  necessary  to  know  what 
part  of  the  cortex  registers  certain  experiences  in  order  that  we 
may  be  able  to  tell  just  what  symptoms  would  be  produced  by 
injury  of  a  given  part  of  the  brain.  Conversely,  this  knowledge 
having  been  obtained  we  may  be  able  to  state  what  part  of  the 
brain  has  been  injured  from  the  observation  of  certain  symptoms. 
The  cortex  as  has  been  said  is  divided  into  certain  so-called  cen- 
ters. The  frontal  area  is  concerned  with  conscious  selective  action, 
the  Rolandic  area  with  motor  memories  and  the  .reproduction  of 
these  memories  which  results  in  voluntary  motion,  while  the  spinal 
level  is  concerned  with  reflex  and  vegetative  automatism.  Experi- 
ment on  lower  animals  and  observation  of  diseased  and  traumatic 
conditions  in  the  human  being  have  determined  the  function  of 
many  regions  of  the  cortex,  but  there  are  still  many  areas  the 
function  of  which  remains  unknown.  For  obvious  reasons  the 
more  complex  and  the  higher  the  function  of  a  given  area,  the 
more  difficult  it  becomes  to  ascertain  the  nature  of  that  function. 
The  occipital  lobe  on  either  side  of  the  calcarine  fissure  is  con- 
cerned with  the  memories  of  sights  seen;  the  temporo-sphenoidal, 
especially  the  left,  with  the  memory  of  sounds  heard  and  muscular 
memories;  the  left  angular  gyrus  with  the  memory  of  written 
speech;  the  posterior  part  of  the  frontal  lobe  with  the  memory  of 
printed  speech;  and  the  third  frontal  convolution  on  the  left  side 
is  concerned  with  the  memory  of  spoken  speech.  Stereognostic 
sense  is  located  in  the  parietal  lobe.  The  centers  in  the  Rolandic 
sensori-motor  area  are  disposed  inversely  (i.  e.,  the  centers  for  the 
head  are  below  those  for  the  upper  extremity,  etc.).  The  centers 
for  the  lower  extremity  extend  onto  the  mesial  surface  of  the 
hemisphere.  Fracture  of  the  vault  may  injure  one  or  more  of 
these  areas.  If  the  injury  is  slight,  and  the  center  is  not  de- 
stroyed, the  lesion  is  said  to  be  irritative  and  the  center  overacts. 


402  FRACTURES   AND   DISLOCATIONS 

If  the  lesion  is  more  serious  and  the  center  is  destroyed  the  func- 
tion of  that  center  is  lost.  Thus  if  the  Rolandic  area  is  irritated, 
the  regions  of  the  body  supplied  by  the  corresponding  centers  are 
thrown  into  unwonted  activity  or  spasm ;  but  if  the  lesion  is  more 
severe,  function  of  the  center  is  lost.  This  results  in  loss  of  mem- 
ory for  muscular  movements  and  consequently  they  cannot  be 
voluntarily  reproduced.  If  Broca's  convolution  is  destroyed,  the 
memory  for  the  acts  connected  with  motor  speech  is  lost  and  con- 
sequently the  movements  of  motor  speech  cannot  be  reproduced. 
Of  recent  years,  however,  there  has  been  some  doubt  as  to  the 
function  of  Broca's  convolution,  and  it  is  not  now  thoufi'lit  to  be 
so  essential  to  speech  as  formerly. 

If  the  lesion  penetrates  below  the  cortex,  the  fibres  which  asso- 
ciate these  centers  may  be  lacerated  and  the  normal  communica- 
tion between  centers  is  interfered  with.  Thus  a  given  center  can- 
not be  stimulated,  as  in  tlie  normal  person,  by  the  activities  of  an 
associated  center.  If  a  center  concerned  with  speech  is  destroyed 
and  the  function  of  that  part  of  the  cortex  lost  the  patient  is  said 
to  suffer  from  aphasia.  If  the  fibres  connecting  a  given  cortical 
center  with  some  other  cortical  center  are  lacerated  the  patient  is 
said  to  suffer  from  intereortical  aphasia.  If  the  center  destroyed 
is  concerned  witli  motor  memories  the  patient  has  motor  aphasia. 
If  the  centers  concerned  with  registering  purely  sensory  ideas  are 
destroyed  the  patient  has  sensory  aphasia. 

The  base  of  the  brain  also  has  centers  distributed  through  its 
substance  which  preside  over  various  important  functions  of  a 
lower  order  than  those  found  in  the  cortex.  These  centers  have 
running  through  them  fibres  from  the  cortex  of  the  brain,  so  that, 
in  case  of  injury,  we  have  not  only  symptoms  of  lesions  in  these 
lower  centers  but  also  symptoms  of  interruptions  of  impulses  from 
the  cortex. 

In  the  anterior  fossa  we  have  the  center  for  smell  situated  in 
the  olfactory  lobe.  In  the  middle  fossa  we  have  the  optic  thala- 
mus, the  corpora  quadrigemina,  and  the  crus.  The  optic  thalamus 
is  concerned  with  emotional  facial  expression  and  lesions  of  this 
body  may  give  rise  to  athetosis  or  incoordination  of  the  paralyzed 
hand  and  pain  in  the  paralyzed  limb.  The  anterior  corpora  quad- 
rigemina are  associated  with  motion  of  the  eyeballs  and  acuity  of 
vision,  the  posterior  corpora  quadrigemina  are  related  to  hearing 
and  equilibration.     The  crus  contains  the  nucleus  of  the  third  and 


FRACTURES   OP   THE   SKUIjL  403 

fourth  nerves  and  longitudinal  fibres  passing  from  the  cerebral 
cortex  to  the  spinal  cord.  Lesions  of  this  body  give  a  character- 
istic set  of  symptoms  in  accordance  with  the  nuclei  and  fibres 
contained  within  it:  paralysis  of  the  third  and  fourth  nerves  will 
deprive  all  the  muscles  of  the  eye  of  their  nerve  supply  except  the 
external  rectus;  injury  to  the  longitudinal  fibres  may  cause  hemi- 
plegia of  the  opposite  side  and  hemianopsia  may  be  present  if  the 
adjacent  optic  tract  is  injured  by  pressure.  If  both  crura  are 
damaged  we  have  a  double  hemiplegia  with  paralysis  of  the  third 
and  fourth  nerves  on  both  sides,  and  in  some  instances  optic  neu- 
ritis. In  the  pons  we  have  a  continuation  of  the  longitudinal 
fibres  of  the  crura,  the  thermogenic  center,  and  the  nuclei  of  the 
fifth,  sixth,  and  seventh  cranial  nerves.  Injury  to  the  fibres  of 
the  crura  as  they  pass  through  the  pons  may  produce  hemiplegia, 
disturbance  of  the  thermogenic  center,  extremely  high  tempera- 
ture, and  injury  to  the  three  cranial  nerve  nuclei  will  be  followed 
by  symptoms  peculiar  to  each  nerve.  Injury  to  the  nucleus  with 
loss  of  function  in  each  nerve  will  be  as  follows :  for  the  fifth, 
hemifacial  anesthesia  with  paralysis  of  the  muscles  of  mastication ; 
for  the  sixth,  paralysis  of  the  external  rectus  of  the  eye ;  and  for 
the  seventh,  motor  paralysis  of  the  muscles  of  the  face.  Bilateral 
symptoms  will  be  present  if  the  lesion  involves  both  sides  of  the 
pons. 

The  usual  anatomical  division  of  the  bulb  into  pons  and  medulla 
is  purely  artificial.  For  practical  surgical  purposes  they  should 
be  considered  together. 

The  medulla  resembles  the  pons  and  crura  in  containing  longi- 
tudinal fibres  from  the  cortex  together  with  cranial  nerve  nuclei. 
The  characteristic  symptoms  of  lesions  of  the  medulla  will  depend 
on  the  nuclei  which  it  contains.  In  the  upper  border  of  the 
medulla  is  the  nucleus  of  the  eighth  cranial  nerve  which  also  pro- 
jects into  the  pons;  in  the  lower  half  of  the  fioor  of  the  fourth 
ventricle  we  have  the  nuclei  of  the  ninth,  tenth,  and  eleventh 
cranial  nerves  and  at  a  slightly  lower  level  is  found  the  nucleus 
of  the  twelfth.  The  vomiting  center,  the  vaso-motor  center  and 
numerous  other  centers  governing  various  functions  in  the  body 
are  situated  in  the  bulb,  but  as  yet  too  little  is  accurately  known 
concerning  them  to  be  of  considerable  surgical  value. 

Further  back  in  the  posterior  fossa  we  have  the  cerebellum 
which  is  concerned  in  coordinating  the  various  muscular  activities 


40-4  FRACTURES   AXD    DISLOCATIONS 

of  the  body  and  in  the  complex  process  of  equilibration.  Another 
function  of  the  cerebellum  consists  in  the  peculiar  power  of  im- 
parting the  proper  degree  of  force  to  muscular  movements.  In- 
jury to  the  cerebellum  may  give  rise  to  cerebellar  ataxia,  obstinate 
projectile  vomiting,  and  various  forms  of  paralyses  and  anes- 
thesias. The  association  of  the  cerebellum  with  the  pons,  medulla, 
basal  ganglia  and  cortex  is  so  complete  that  it  is  difficult  to  deter- 
mine the  source  of  these  varied  symptoms. 

The  foregoing  enumeration  is  by  no  means  t-oniplete  as  regards 
location  and  function  of  the  cortical  centers  and  basal  ganglia ; 
there  is  still  considerable  dispute  concerning  the  functions  of  these 
centers  and  there  are  numerous  other  centers  which  as  yet  remain 
with  functions  unknown.  There  are  many  symptoms  occurring  in 
head  injuries  which  could  be  properly  explained  if  we  knew  more 
of  the  anatomy  and  physiology  of  the  brain,  but  for  the  present 
the  description  given  will  be  found  of  service  in  roughly  deter- 
mining the  seat  of  injury  in  fracture  of  the  skull. 

Etiology. — Trauma  is  the  cause  of  fracture  of  the  skull  but  the 
nature  and  the  degree  of  violence  are  so  extremely  variable  that 
the  resultant  conditions  show  the  greatest  differences  in  detail. 
The  trauma  may  be  sustained  over  a  small  or  large  area  of  the 
skull;  the  vulnerant  body  may  travel  at  a  high  rate  of  speed  (bul- 
let) or  at  a  slow  rate  (club)  ;  the  violence  may  be  direct  or  it  may 
be  transmitted  through  the  spinal  column  or  inferior  maxilla. 
The  violence  may  be  circumscribed  or  the  head  may  be  squeezed 
or  crushed  betw^een  heavy  objects. 

Fracture  of  the  skull  constitutes  from  four  to  six  percent  of  all 
fractures  and  possibly  more,  since  we  are  learning  of  recent  years 
that  the  milder  forms  of  the  condition  have  only  too  frequently 
gone  unrecognized  in  the  past.  Statistics  are  specially  misleading 
in  this  particular  injury,  for  the  following  reasons:  in  the  first 
place  the  most  severe  cases  never  reach  the  hospital  because  of 
immediate  death,  and  secondly  the  condition  is  frequently  asso- 
ciated and  confused  with  other  injuries;  thii'dly,  the  milder  cases 
are  often  successfully  treated  at  home,  and  in  many  cases  are  not 
classified  as  fractures  because  of  mistaken  diagnoses.  For  these 
reasons  figures  derived  from  a  service  such  as  the  police  surgeon's 
will  come  nearer  the  truth,  since  it  includes  all  classes  of  fractures 
ranging  from  the  mildest  to  those  immediately  fatal.  Occupation 
is  an  inqjortant  element  in  the  etiology.     Fracture  of  the  skull  is 


FRACTURES   OF    THE   SKULL  405 

most  frequently  found  in  the  male  and  in  middle  life.  The  skull 
in  the  aged  is  much  more  easily  fractured  than  that  of  the  person 
in  middle  life,  but  on  the  other  hand  those  advanced  in  years  are 
not  so  exposed  to  injury. 

Mechanism  and  Pathology. — The  various  ways  in  which  the  skull 
is  broken,  the  manner  in  which  fragments  are  displaced,  and  the 
region  of  the  cranium  involved  have  all  been  subjects  of  careful 
investigation,  and  terms,  to  designate  the  peculiarities  of  the  con- 
ditions, have  been  applied.  Before  considering  the  mechanism  of 
these  fractures,  it  is  necessary  to  again  refer  to  the  anatomy  with 
respect  to  the  peculiar  formations  of  the  vault  and  base.  The 
structure  of  the  skull  is  peculiar  to  itself  and  any  attempt  to  liken 
the  manner  in  which  it  breaks  to  that  of  other  objects  can  at  best 
be  but  incomplete.  Circumscribed  blows  upon  the  vault  of  the 
skull  commonly  produce  a  local  depressed  fracture  with  or  without 
injury  to  the  underlying  structures.  A  more  extreme  blow  or 
squeezing  of  the  skull  will  result  in  fissures  (with  or  without  de- 
pression) which  are  prone  to  extend  towards  and  involve  the  base. 
A  certain  degree  of  trauma  can  be  withstood  by  the  vault  without 
apparent  injury,  the  shock  being  absorbed  by  the  natural  elas- 
ticity of  the  bone.  If  the  trauma  be  a  little  greater,  and  the  skull 
bent  inward  sufficiently,  the  internal  table  may  give  and  we  then 
have  a  fracture  of  the  inner  table  alone ;  a  condition  frequently 
described  in  text-books,  but  rarely  seen  in  practice.  A  still  greater 
trauma  results  in  dissolution  of  continuity  of  the  entire  thickness 
of  the  bone.  On  the  other  hand  a  blow  from  a  sharp  cutting  in- 
strument may  fracture  the  outer  table  while  the  inner  table  re- 
mains intact.  The  skull  may  be  fractured  by  "bending"  or  by 
"bursting."  When  violence  is  applied  to  the  skull  in  a  circum- 
scribed region  the  immediate  site  of  injury  is  "bent"  inward  with 
resultant  local  fracture  which  is  said  to  be  "fracture  by  bending." 
When  the  violence  is  applied  over  a  larger  area  and  more  slowly, 
lines  of  fracture  may  be  found  radiating  from  the  site  of  impact, 
often  involving  the  base.  The  action  may  be  likened  to  the  break- 
ing of  a  nut  in  a  nut-cracker.  This  form  of  fracture  is  spoken 
of  as  "fracture  by  bursting";  the  most  striking  examples  of  which 
are  seen  in  instances  in  which  the  head  has  been  caught  and 
crushed  between  two  heavy  objects.  We  often  have  evidences  of 
both  the  bending  and  bursting  action  in  a  given  case.  If  the  skull 
were  of  a  uniform  thickness  throughout,  the  mechanism  would  be 


406  FRACTURES   AND   DISLOCATIONS 

iinich  easier  to  determine.  As  it  is  we  find  the  peculiarities  in 
the  structure  of  the  skull  directly  influence  the  directions  which 
fissures  take.  When  fractures  of  the  vault,  between  the  frontal 
and  parietal  eminences,  involve  the  base  they  are  frequently  ac- 
companied by  fissures  extending  into  the  middle  fossa.  When 
fractures  posterior  to  the  parietal  eminence  are  accompanied  by 
basal  fissures  they  usually  extend  into  tlie  posterior  fossa  and  in 
like  manner  those  anterior  to  the  frontal  eminence  involve  the 
anterior  fossa.  In  gunshot  wounds,  especially  when  produced  by 
the  modern  high-pressure  bullet,  the  skull  sometimes  presents  what 
would  seem  to  be  an  explosive  effect  similar  to  that  produced  by 
shooting  through  a  barrel  filled  with  water.  The  nature  of  the 
vulnerant  body  is  an  extremely  important  element,  for  example ; 
the  completely  jacketed  high-velocity  rifle  ball  will  usually  pene- 
trate cleanly,  is  not  prone  to  carry  in  any  extraneous  materials, 
and  the  wound  is  frequently  sterile  throughout.  On  the  other 
hand  a  blow  from  a  hammer  besides  driving  a  portion  of  the  bone 
into  the  brain  will  frequently  be  found  to  have  carried  in  hair, 
dirt,  or  felt,  and  the  wound  is  therefore  much  more  liable  to 
infection.  Fracture  by  contrecoup  has  been  the  subject  of  much 
discussion  and  although  it  may  be  possible  for  fracture  to  occur 
at  the  opposite  pole  of  the  head  as  a  result  of  the  meeting  of 
vibrations,  j^et  its  occurrence  has  been,  to  say  the  least,  greatly 
exaggerated.  Most  of  the  so-called  contrecoup  fractures  will 
upon  further  investigation  be  found  to  be  fractures  by  bursting 
or  the  result  of  a  second  blow  on  the  head.  For  example :  a  man 
sustains  a  blow  on  the  forehead  fracturing  the  anterior  part  of 
the  skull,  falls  heavily  to  tlie  sidewalk  and  strikes  the  back  of  his 
head,  producing  a  second  fracture  in  the  occipital  region;  this 
second  fracture  is  not  infrequently  considered  a  fracture  by 
contrecoup  when  in  realit^y  it  is  but  the  result  of  a  second  blow. 
The  outline  and  position  assumed  bj^  depressed  fragments  will  cor- 
respond, more  or  less,  to  the  shape  of  that  portion  of  the  vulnerant 
body  which  has  produced  the  fracture.  The  terms  ''gutter," 
"pond,"  etc.,  are  used  to  indicate  the  position  of  the  fragments. 
When  the  fragment  is  depressed  and  only  partially  detached  from 
the  remainder  of  the  skull,  the  unbroken  bridge  of  bone  connecting 
the  fragment  may  impart  sufficient  spring  to  the  depressed  portion 
to  pinch  and  securely  hold  extraneous  materials  such  as  hair  and 
felt.     The  injuries  inflicted  by  missiles  vary  with  the  nature  of 


FRACTURES   OF    TJIK    SKULL  407 

the  projectile,  and  the  weapon  from  which  fired.  The  lead  ball 
from  an  ordinary  32  caliber  revolver  produces  considerable  dam- 
age at  the  point  of  entrance,  and  very  commonly  remains  within 
the  skull,  even  when  fired  at  close  ran^^e.  A  38  or  44  caliber  is 
much  more  likely  to  pass  through  the  skull.  The  partially  jack- 
eted or  mushroom  bullet  usually  passes  through  the  head  with 
more  or  less  shattering  of  bone  at  the  wound  of  entrance,  and 
extreme  damage,  comminution  and  laceration  at  the  wound  of  exit. 
The  completely  jacketed  high-velocity  projectile,  such  as  used  in 
the  army,  may  penetrate  the  head  with  a  minimum  amount  of 
trauma;  the  wound  of  entrance  is  small  and  clean  cut,  the  wound 
of  exit  is  only  a  trifle  larger.  Any  projectile  either  low  or  high 
in  velocity  is  likely  to  produce  extensive  comminution  when  the 
skull  is  struck  a  gianeing  IjIow. 

Symptoms  of  Concussion,  Contusion,  Laceration  and  Com- 
pression.— The  symptoms  accompanying  fracture  of  the  skull  are 
firstly,  those  of  the  fracture  itself  and  secondly,  those  result- 
ing from  injury  to  the  encephalon,  which  may  be  either  general 
or  localizing.  They  will  depend  upon  the  extent,  nature  and  posi- 
tion of  the  injury  sustained  by  the  brain.  Symptoms  of  fracture 
are  often  very  meager,  and  of  little  importance  aside  from  the 
concomitant  brain  injury.  Before  entering  upon  the  symptoms 
occurring  in  connection  with  fractures  of  the  skull  and  injuries 
to  the  brain,  it  will  be  necessary  to  consider  a  group  of  conditions 
which  occurs  either  with  or  without  fracture,  namely, — concussion, 
contusion,  laceration  and  compression.  At  least  one  and  some- 
times all  of  these  four  conditions  are  associated  with  fracture  of 
the  skull,  but  the  fact  that  it  is  possible  for  them  to  be  present 
without  accompanying  injury  of  the  bone  renders  the  diagnosis 
of  fracture  of  the  skull  more  difficult.  Concussion  and  contusion 
of  the  brain  are  really  the  same  condition,  the  difference  being  one 
of  degree. 

Concussion  consists  of  a  jarring  of  the  brain-substance  which 
results  from  rapidly  putting  the  head  into  motion,  as  by  a  blow; 
or  by  suddenly  stopping  it  while  in  motion,  as  in  a  fall.  The 
symptoms  of  concussion  Avill  vary  with  the  severity  of  the  injury. 
When  slight,  the  patient  is  momentarily  dazed,  develops  more  or 
less  of  a  headache  and  may  suffer  from  vertigo  and  nausea.  When 
the  jarring  of  the  brain-substance  is  more  severe,  the  patient  be- 
comes unconscious,  with  general  muscular  relaxation  and  a   cold 


408  FRACTURES   AND   DISLOCATIONS 

elanuny  skin.  There  may  l)e  loss  of  si)liiiK'teri('  eoiitrol  at  the  time 
of  the  accident,  later  on  the  sphincters  may  fail  in  reaction,  with 
resultant  overdistention  of  the  bladdei-  and  howt'ls.  There  is  gen- 
eral systemic  (depression,  the  pnlse  is  weak  and  tliready:  the  pupils 
are,  as  a  rule,  equal,  with  a  tendency  towards  dilatation.  Keaction 
to  light  is  present  though  sluggish.  The  patient  recovers  gradu- 
ally from  the  unconscious  state,  requiring  some  hours,  in  severe 
cases,  before  complete  consciousness  and  good  judgment  are  re- 
stored. As  the  patient  recovers  he  is  prone  to  ask  many  questions, 
which  are  usually  concerning  his  whereabouts,  the  nature  of  the 
accident,  etc.  The  manner  in  which  these  ciuestions  are  put  and 
repeated  is  most  characteristic  of  the  condition.  For  instance,  he 
may  ask  where  he  is;  then  what  happened  to  him,  how  it  hap- 
pened ;  and  where  some  companion  may  be.  These  questions  are 
as  a  rule  slowly  repeated  in  the  same  order,  regardless  of  the  fact 
that  they  may  have  been  repeatedly  answered.  It  is  a  peculiar 
fact  that  with  the  loss  of  memory  for  the  accident  and  the  subse- 
quent unconsciousness,  there  is  also  the  loss  of  memiory  for  events 
immediately  preceding  the  accident.  This  loss  of  memory  pre- 
ceding the  accident  will  cover  a  period  proportionate  to  the  sever- 
ity of  the  concussion,  sometimes  many  hours,  days  or  even  months. 
As  memory  returns,  this  blank  space  is  lessened  from  both  ends 
until,  with  complete  recovery,  the  patient  is  able  to  remember 
everything  that  occurred  outside  the  period  of  coma.  With  re- 
turning consciousness  the  patient  is  often  able  to  state  his  name 
before  it  is  possible  for  him  to  recollect  anything  else.  It  will  be 
some  time  later  before  he  is  capable  of  answering  questions  in- 
volving numbers,  such  as  his  address,  date  of  the  month,  etc.  It 
is  important  in  this  regard  to  see  to  it  that  the  patient  has  fully 
regained  his  good  judgment  as  well  as  his  consciousness,  since  seri- 
ous consequences  may  ensue  if  he  be  allowed  to  go  about  his  busi- 
ness unattended.  For  example,  he  may  be  able  to  state  his  name, 
give  his  occupation,  tell  what  business  he  was  about  when  injured, 
etc.,  and  yet  if  released  may  be  unable  to  find  his  way  home  or 
may  perform  some  act  contrary  to  good  judgment  before  he  has 
thoroughly  regained  his  mental  balance  and  is  himself  again.  It 
is  therefore  wise  to  keep  him  under  observation  for  at  least  a  few 
hours  following  the  accident. 

Contusion. — Contusion  as  previously  stated  is  but  a  more  severe 
degree  of  concussion  and  accordingly  we  find  the  symptoms  of  con- 


FRACTURES   OP   THE   SKULL  409 

cussion  present  in  exaggerated  form.  Pathologically  there  is  this 
difference  between  concussion  and  contusion :  concussion  shows  no 
characteristic  post-mortem  findings,  while  contusion  frequently 
shows  minute  punctate  hemorrhages  throughout  the  substance  of 
the  brain.  Like  concussion  there  will  be  unconsciousness,  prostra- 
tion, disturbances  in  sphincteric  control,  cold  clammy  skin,  weak 
thready  pulse,  etc.  The  unconscious  period  is  prolonged  and  re- 
covery protracted,  so  that  the  condition  may  cover  a  period  of 
weeks  or  even  longer.  Recovery  from  unconsciousness  is  slower, 
and  in  rare  instances  the  condition  may  be  followed  by  mania  end- 
ing in  recovery,  death  or  dementia.  Protracted  and  severe  head- 
ache is  not  uncommon  and  vomiting  is  often  persistent.  During 
semiconsciousness,  headache  is  evidenced  by  the  patient  putting 
his  hand  to  his  head  and  later  when  able  to  talk  he  complains  of 
the  pain.  If  the  intracranial  disturbance  is  severe  enough  to  be 
irritative,  one  or  both  pupils  may  show  contraction,  according  to 
the  cerebral  regions  involved.  During  recovery,  which  is  gradual, 
the  patient  may  develop  an  active  delirium  and  if  not  restrained 
may  leave  his  bed  and  wander  about  aimlessly.  During  this  semi- 
conscious period  he  often  assumes  a  perverse,  obstinate,  mental 
attitude  which  renders  nursing  difficult  and  sometimes  even  dan- 
gerous. In  extreme  cases  the  patient  may  pass  into  a  typhoid 
state  with  sordes,  coated  tongue,  sphincteric  disturbances,  low  mut- 
tering delirium,  subsultus  tendinum,  etc.  When  contusion  is  se- 
vere or  prolonged,  localizing  symptoms  are  likely  to  develop ;  the 
condition  is  then  recognized  as  one  of  laceration  or  compression 
as  well  as  contusion.  When  symptoms  of  compression  develop 
early  they  are  likely  to  be  due  to  hemorrhage  or  laceration,  but  if 
they  come  on  late,  edema  of  the  brain  is  probably  the  cause. 

Laceration. — 'Laceration  of  the  brain  tissue  without  fracture 
may  be  considered  an  intensified,  local  contusion  and  is  due  to  the 
same  causes.  When  it  is  the  direct  result  of  depressed  fragments 
or  the  entrance  into  the  skull  of  the  vulnerant  body  we  find  that 
the  condition  may  occur  more  or  less  independently  of  the  symp- 
toms which  usually  accompany  concussion,  contusion  and  com- 
pression. Laceration  may  accompany  contusion  and  concussion 
without  giving  rise  to  localizing  symptoms  if  the  region  of  the 
brain  involved  is  not  capable  of  producing  peripheral  disturbances 
in  function.  When  the  region  injured  is  within  some  of  the  so- 
called  silent  areas,  we  have  no  localizing  symptoms.     Contusions 


410  FRACTURES    AND    DISLOCATIONS 

and  lac-orations  ol'  tlie  brain  are  a  frequent  aet'onii)aniiiiciit  of  frac- 
tures of  the  base,  the  most  frequent  sites  being  the  under  surfaces 
of  the  frontal  lobes  and  the  tips  of  the  spheno-temporal  lobes.  In 
depressed  fractures  of  the  vault  it  is  common  to  find  the  cortex 
beneath  the  fragments  .suffering  from  laceration.  The  pulse  is 
usually  weak  and  rapid,  resembling  concussion  in  this  respect;  in- 
creased tension  and  slow  pulse  are  to  be  expected  only  when  com- 
pression develops.  The  temperature  in  both  concussion  and 
contusion  is,  as  a  rule,  sul)normal  but  as  the  conditions  merge  into 
the  more  severe  grades  of  brain  injury,  such  as  laceration,  the 
temperature  rises  above  normal. 

Compr€<ision. — The  ]ihysical  phenomena  indicating  compression 
of  brain  tissue  vary  widely  with  the  location,  rai)idity  and  degree 
of  pressure.  The  cranial  contents  are  fluid  and  semifluid,  hence 
the  question  of  inti-acranial  pressure  is  essentially  one  of  hydro- 
dynamics. The  cerebrospinal  fluid  occupies  a  considerable  space 
between  the  brain  and  the  skull,  esi^ecially  at  the  base,  and  when 
hemorrhage  occurs  within  the  skull  this  fluid  is  displaced  into  the 
spinal  spaces  to  make  room  for  the  clot  within  the  cranium. 
Under  such  conditions  the  capacity  of  the  skull  remains  the  same 
and  the  fluid  nature  of  the  contents  precludes  actual  condensation 
or  compression,  yet  the  pressure  pervading  the  entire  mass  is  in- 
creased, accounting  to  some  extent  for  the  symptoms.  This 
pressure  impedes  the  circulation  within  the  skull,  resulting  in 
intracranial  anemia,  which  is  in  turn  compensated  for  by  the 
activity  of  the  vasomotor  centers  which  raise  the  general  blood 
pressure.  Hence  the  slow,  high-tension,  bounding  pulse  seen  in 
compression  of  the  encephalon.  If  the  pressure  be  slowly  applied, 
allowing  the  cerebrospinal  fluid  ample  time  for  displacement,  a 
surprisingly  large  clot  may  result  with  but  mild  symptoms;  on  the 
other  hand  pronounced  and  rapid  symptoms  may  accompany  a 
small  quick  hemorrhage.  The  most  pronounced  symptoms,  there- 
fore, accompany  large  rapid  hemorrhages  such  as  occur  from  the 
middle  meningeal  artery,  while  the  mildest  and  slowest  of  onset 
are  seen  in  cases  where  a  small  clot  has  developed  gradually  from 
one  of  the  smaller  veins.  During  compression,  the  intracranial 
pressure  will  be  approximately  the  same  throughout  the  skull  but 
the  displacement  of  cerebral  tissue  will  be  greatest  surrounding 
the  foreign  material,  decreasing  in  all  directions  within  the  skull 
inversely  as  the  square  of  the  distance.     The  region  of  greatest 


FRACTURES    OF    TIIK    SKHIJj  411 

displacement  will  show  the  greatest  amount  of  cell  injury  and 
dissociation  between  cells,  and  will  therefore  be  the  area  to  suffer 
most  functionally.  If  the  foreign  accumulation  takes  place  rap- 
idly the  function  of  the  cortex  may  be  destroyed  at  once,  but  if 
the  pressure  is  exerted  more  gradually  there  will  be  irritation  with 
overaction  of  the  centers,  followed  by  paralysis  if  the  process  be 
carried  far  enough.  Accordingly  when  motor  areas  are  the  seat 
of  displacement  we  have  spasm  of  groups  of  muscles  according  to 
the  cortical  regions  involved ;  this  overaction  or  convulsion  is  fol- 
lowed by  paralysis  if  the  pressure  is  continued  and  increased. 
Compression  may  be  the  result  of  hemorrhage  from  the  meningeal 
or  cerebral  vessels,  from  edema  following  contusion,  from  depressed 
fragments  of  bone  and  from  the  forcible  introduction  of  foreign 
bodies  through  the  skull  and  into  the  brain. ^ 

Symptoms.— The  most  common  causes  of  traumatic  compression 
are  the  depression  of  fragments  and  hemorrhage  from  the  menin- 
geal vessels,  especially  the  middle  meningeal.  The  same  trauma 
which  causes  compression  almost  invariably  produces  concussion, 
and  if  the  concussion  does  not  clear  up  before  the  symptoms  of 
compression  develop,  the  patient  will  present  the  symptoms  of  both 
conditions  simultaneously.  A  return  to  the  unconscious  state  dur- 
ing recovery  from  concussion  is  therefore  a  symptom  characteristic 
of  compression,  the  conscious  or  semiconscious  interval  represents 
a  condition  of  the  patient  in  which  he  is  coming  out  of  the  un- 
consciousness of  concussion  before  the  clot  has  assumed  sufficient 
size  to  produce  coma  from  increased  intracranial  pressure  and 
displacement. 

The  sjmiptom-complex  of  fracture  of  the  skull  is  so  variable  and 
the  subject  so  extensive  that  it  is  difficult  to  study  the  numerous 
symptoms  in  detail,  and  at  the  same  time  keep  a  clear,  concise 
and  comprehensive  view  of  the  subject  as  a  whole.  For  this  reason 
we  will  consider  first,  in  tabulated  form,  the  most  frequent  symp- 
toms which  may  accompany  the  condition,  after  which  they  will 
be  taken  up  in  detail.  The  same  difficulties  which  confront  us  in 
the  study  of  these  conditions  prevail  in  dealing  with  the  case  at 
the  bedside,  and  unless  we  have  some  systematized  method  of  pro- 
cedure we  are  more  than  likely  to  overlook  some  of  the  symp- 
toms. 


1  Pathological  conditions   such   as   tumors,   cysts,   etc.,    are   not  here   considered   as  they 
are  not  related  to  fractures,   except  as  sequelae. 


412  FRACTURES   AND   DISLOCATIONS 

For  convonit'iK-e  the  syiuptoins  may  be  dividetl  into  loeal,  gen- 
eral and  localizing. 

Local  symptoms. 

1.  Pain  in  the  region  of  the  fracture. 

2.  Scalp  wounds. 

3.  Depressions  or  fissures  in  the  bone. 

4.  Mobility  and  crepitus. 

5.  Escape  of  blood,  cerebrospinal  fluid  or  brain  tissue. 

6.  Ecchymosis. 

7.  Emphysema. 

General  symptoms. 

8.  ITneonseiousness. 

9.  Vomiting. 

10.  Headache. 

11.  Vertigo. 

12.  General  flaccidity  and  loss  of  deep  reflexes. 

13.  Variations  in  pulse  and  blood  pressure. 

14.  Variations  in  respiration. 

15.  Variations  in  temperature. 

Localizing  symptoms. 

16.  Deviations  in  the  positions  of  the  eyes. 

17.  Alterations  in  pupillary  reactions. 

18.  Local  motor  and   sensory   paralyses   and   disturbar.ees   i'l 

muscular  tone. 

19.  Disparity  in  deep  reflexes  of  two  sides. 

20.  Disparity  in  temperature  of  two  sides. 

21.  Disturbances  in  higher  psychic  function. 

22.  Aphasias. 

23.  Cranial  nerve  symptoms. 

It  is  not  to  be  supposed  that  any  given  patient  will  present  all 
of  the  above  tabulated  symptoms,  and  no  one  symptom  will  be 
present  in  all  cases.  Each  patient  examined  will  show  a  different 
combination  of  symptoms  as  a  result  of  the  variations  in  bone  and 
brain  injury  which  occur  in  different  instances.  Most  fractures 
of  the  vault  present  a  more  or  less  complete  set  of  local  symptoms, 
being,  a.s  a  rule,  accompanied  by  wounds  of  the  scalp.  In  frac- 
tures of  the  vault  localizing  symptoms  will  be  present  depending 


FRACTURES   OP    THE   SKULL  413 

upon  whether  or  not  the  motor  areas  have  been  injured.  Frac- 
tures of  the  base  are  less  productive  of  local  symptoms,  tliough 
the  general  symptoms  are  usually  more  pronounced. 

Local  Symptoms. — 1.  Pain  in  the  region  of  fracture  is  present 
if  the  patient  is  conscious;  in  other  w^ords,  pain  is  present  if  the 
encephalon  is  capable  of  recognizing  the  afferent  impulses  which 
constitute  pain.  In  many  cases  of  semiconsciousness  pain  is  indi- 
cated by  groaning  or  by  repeatedly  carrying  the  hand  to  the  seat 
of  the  injury.  Pain  is  present  in  simple  scalp  wounds  but  is  not 
as  severe  as  that  which  results  when  the  skull  is  fractured  and  the 
meninges  injured. 


Fig.  521. — Depressed  fracture  of  the  vault  produced  by  a  fragment  of  an  explod- 
ing shell  during  the  Franco-Prussian  war.  History  of  severe  infection.  No  untoward 
late  results. 

2.  The  symptoms  of  scalp  wounds  do  not  necessarily  accompany 
those  of  fracture  of  the  skull,  but  the  frequent  association  of  the 
two  conditions  in  fracture  of  the  vault  would  render  the  picture 
misleading  if  the  symptoms  of  scalp  injury  were  not  included 
under  the  local  symptoms  of  fracture  of  the  skull  (see  "Scalp 
Wounds, "page  382). 

3.  Depressions  of  hone  may  sometimes  be  recognized  by  inspec- 
tion alone,  though  the  symptom  is  usually  found  only  by  palpa- 
tion and  exploration  of  the  scalp  wound.  Fissures  may  be  present 
radiating  from  a  depression  or  existing  independently,  and  can  be 
recognized  only  by  examination  of  the  bone. 

4.  Motility  and  crepitus  may  be  present  in  rare  instances  but 
are,  as  a  rule,  only  elicited  during  exploration  of  the  bones  of  the 


414 


FRACTTHHS    .WH    DlSl,()C.\riONS 


Fig.    522. — Old   depressed  fraoture  in  frontal  region.      Injury   su.sl.iinrd   duiins  cliild- 
hood.      IS'o  symptoms   whatever   of   intracranial  disturbance. 


Fig.    523. — Depressed    fracture    of    skull    in    left    parietal    region    of  about    eighteen 

years'   standing.     Not  followed  by   any   late   symptoms.      Patient  presents  himself    at   this 

time  for   treatment  of   slight   scalp   wound  seen   at  the  iipper   margin  of  the  old   depres- 
sion. 


PRACTITKES    Ol''    TIIK    SKIITIj 


415 


Fig  524  — Depressed  fracture  of  the  vault  without  sj'mptoms  for  over  twenty 
years.  Of  late  the  patient  complains  of  pain  at  the  seat  of  fracture  followed  at 
times  by  general  headache,  vertigo  and  dizziness.  An  example  of  the  development  of 
late   symptoms   in    instances   in   which   depression   is    allowed   to   go   uncorrected. 


Fig  525. — Fracture  of  posterior  fossa  due  to  fall  on  the  back  of  head.  No  symp- 
toms suggestive  of  the  condition  until  the  day  following  the  injurj'  (nearly  twenty-four 
hours).  Patient  went  about  his  business  stating  that  he  was  perfectly  well  and  did 
not  desire  any  attention.  Death  due  to  intracranial  pressure  produced  by  hemorrhage 
from  a  small  vein  in  the  posterior  fossa  which  was  torn  as  it  crossed  the  line  of 
fracture.  Hemorrhage  ultimatelv  covered  the  base  of  the  brain.  Patient  found  dead 
in  bed  next  morning.  Moderate  quantity  of  venous  blood  had  made  its  escape  from 
the  nasal  cavities  during  sleep.  Line  of  fracture  retouched  as  the  photograph  was 
poor,   having  been  taken  by  the  light  of   a   16   c.p.   electric  lamp. 


416 


FRACTURES   AND    DISLOCATIONS 


vault.     A   i'l-ac'tiire   may   enoirek'   the   skull,   dividing;   it    into   two 
portions,  and   with  such  a  condition  it  may  be  possil)le  to  move 


Fis.   526. — Old   depressed   fracture   of   t!ie   frontal   region.      Case   operated    and   bone 
removed.      I'neventful   recovery. 


Fig.  527. — Fracture  running  from  base  to  vault  and  nearly  encircling  the  skull. 
Patient  lived  a  few  hours  following  the  injury.  Photograph  taken  shortly  after  death. 
Lesion  result   of   fall   from    window. 

one  part  of  the  skull  on  the  other,  thus  producing  mobility  and 
sometimes  crepitus. 


FRACTURES   OF    THE   SKULL 


417 


5.  Fracture  through  the  base  of  the  skull  may  allow  the  escape 
of  hlood  or  cerebrospinal  fluid  and  rarely  hrain  tissue  from  the 


Fig.  528. — Sevei'e  comminuted  depressed  fracture  of  tlie  vault,  during  operation. 
A.  represents  a  large  depressed  fragment  of  bone.  B.  represents  the  horseshoe-shaped 
flap  turned  back  to  expose  the  fracture.  The  arrow  to  the  left  is  in  line  with  fracture 
above  the  large  fragment.  The  arrow  to  the  right  is  in  line  with  the  fracture  below 
the   fragment.      The   upper   portion   of   the   fragment   is   considerably    depressed. 


Fig.  529. — Example  of  the  explosive  effect  of  the  modern  high  pressure  missile  at 
close  range.  Wound  inflicted  with  a  32-20  cartridge  fired  from  a  Smith  &  Wesson 
revolver.  (Soft  nose  bullet.)  Picture  taken  about  twenty  minutes  after  injury.  Pa- 
tient lived   about   one   hour. 


ears,  nose,  or  mouth  according  to  the  region  of  fracture.  In  frac- 
ture of  the  vault  these  same  materials  may  escape  direct^  through 
the  scalp  wound  or  into  the  tissues  of  the  scalp  when  the  condi- 


•418 


FRACTIRES    AND    DISLOCATIONS 


tiou  is  not  coinpouiicl.  It  should  be  fciiiciiihcnHl  tliat  a  large  pro- 
portion of  basal  fractures  result  from  tho  extension  of  a  linear  frac- 
ture of  the  vault  into  the  base,  aiul  hence  are  fractures  of  both 
vault  and  base.  The  escape  of  brain  tissue  is  imich  more  com- 
mon in  fi-actui'e  of  the  vault  tlian  it  is  when  the  base  alone 
is  involved.  Hemorrhage  is  extremely  variable  in  quantity  and 
duration.  It  may  be  very  severe  for  a  few  minutes  or  blood  may 
contiinie  to  tlow  in  small  amounts  for  a  period  of  days.  The  flow 
of  cei'ebros|)inal  tluid  is  likely  to  persist  for  at  least  some  hours, 
usually  days,   when  leakau'e  is  once  established.     It   is  conunonly 


Fig.   530. — Bullet   in   head.      Tlie    arrow    points   to   the   opening    in   the    skull   throui^li 
which  the  bullet  entered. 


mixed  with  blood  during  the  first  few  hours  or  the  first  day,  after 
which  it  is  likely  to  become  clear  and  free  from  accompanying 
hemorrhage. 

6.  Eccliymosis  beneath  the  conjunctiva  is  a  common  symptom 
in  fracture  of  the  anterior  fossa  and  may  be  accompanied  by 
exophthalmos  if  the  collection  of  blood  within  the  orbit  is  of  any 
considerable  quantity.     Ecchymosis  beneath  the  eyelids  may  arise 


FRACTURES   OP    THE   SKUIJj 


419 


Vig.  531. — Pronoimced  swelling  and  ecchymosls  of  both  eyes  following  small  scalp 
wound  on  left  side  of  forehead.  Condition  suggestive  of  fracture  of  the  base  of  the 
skull  since  there  has  been  no  trauma  near  the  patient's  right  eye  to  account  for  its 
.swelling    and   blackening. 


Fig.  532. — Case  of  severe  depressed  fracture  of  the  vault.  The  patient  went 
about  for  ten  days  without  any  attention  to  the  condition.  He  then  presented  himself 
for  medical  treatment  because  of  a  headache.  Parts  badly  infected.  Operation  per- 
formed with  elevation  of  the  depressed  fragments.  Recovery.  Two  years  later  he 
committed  suicide  and  the  ealvarium  was  obtained  at  autopsy.  Patient  was  a  hard 
drinker  and  was  drunk  at  the  time  of  the  injury,  which  accounts  for  his  ten  days' 
neglect   of   the   fracture. 


420  FRACTURES  AND  DISLOCATIONS 

from  the  same  causes;  it  usually  spreads  outward  from  the  in- 
ternal canthus  and  is  accompanied  by  subconjunctival  ccchymo-sis. 
Exophthalmos  •with  pronounced  swelling  and  ecchymosis  of  the 
lids  is  commonly  seen  in  suicidal  gunshot  injuries  in  which  the 
revolver  has  been  licld  to  the  temple,  the  ball  li;i\iiig  passed 
through  the  skull  directly  behind  the  orl)its  or  through  tlieir  apices. 
Ecchymosis  about  the  mastoids  and  nape  of  the  neck  is  not  un- 
commonly seen  in  fracture  of  the  posterior  fossa  though  it  rarely 
develops  before  the  first  twelve  or  twenty-four  liours.  Battle's 
sign  consists  of  ecchymosis  following  the  course  of  the  i)osterior 
auricular  artery  and  is  sometimes  seen  in  fi-acture  of  the  posterior 
fossa. 

7.  Emphysema  behind  tlie  ear  or  in  the  region  of  the  glabella 
sometimes  occurs  when  the  fracture  opens  the  mastoid  cells  or 
frontal  sinuses.  Under  such  conditions  air  is  much  more  likely 
to  remain  in  the  tissues  if  there  is  no  accompanying  scalp  wound 
to  allow  its  escape. 

General  Symptoms. — The  general  symptoms  accompanying 
fracture  of  the  skull  are  much  the  same  as  seen  in  concussion, 
contusion,  laceration  and  compression  previously  described. 

8.  TJnconsciousness  is  a  common  state  in  head  injury  and  usu- 
ally obliterates  symptoms  which  might  otherwise  be  of  value  in 
diagnosis  and  treatment.  Although  unconsciousness  accompanies 
most  head  injuries  and  is  more  or  less  proportionate  to  the  severity 
of  the  case,  yet  in  exceptional  instances  it  may  be  of  the  mildest 
type,  or  absent,  even  though  the  condition  be  grave.  Fractures 
of  the  base  are  much  more  uniformly  accompanied  by  unconscious- 
ness than  are  fractures  of  the  vault.  The  degree  of  unconscious- 
ness is  extremely  variable,  ranging  from  cases  of  momentary 
insensibility  to  cases  in  Avhich  the  coma  is  profound.  Roughly 
speaking  the  severe  cases  are  accompanied  by  the  more  i)rofound 
grades  of  unconsciousness.  The  symptom  has  already  been  de- 
scribed under  the  heading  of  concussion,  contusion,  laceration  and 
compression  (page  407). 

9.  Vomiting  is  a  symptom  which  is  commonly  present  in  the 
early  stages  of  fracture  of  the  skull  though  it  is  not  in  any  way 
pathognomonic,  since  it  regularly  occurs  in  concussion  and  allied 
conditions  w^hen  fracture  is  absent.  Vomiting  occurs  in  so  many 
conditions  that  it  is  of  little  significance.  It  is  seldom  present 
after  the  first  few  hours  though  in  severe  cases  it  may  persist  for 


FRACTURES   OF    THE   SKULL  421 

a  considerable  period.  In  rare  instances  the  vomitinf?  may  be 
projectile  in  character  and  unassociated  with  n;nisea.  As  a  late 
symptom  it  may  occur  with  cerebral  tumor  or  abscess. 

10.  Headache  is  a  common  symptom  following  head  injuries  of 
all  kinds.  A  slight  blow  on  the  head  without  disturbances  in 
consciousness,  or  any  other  symptom,  may  be  followed  by  headache 
for  a  day  or  so.  On  the  other  hand,  headache  may  be  the  most 
pronounced  symptom  of  a  serious  brain  lesion.  Headache  as  a 
late  symptom  of  fracture  of  the  skull  is  discussed  on  page  451. 

11.  Vertigo  is  often  present  though  its  recognition  is  frequently 
prevented  by  other  symptoms  such  as  unconsciousness,  prostra- 
tion, etc.  "When  persistent  it  is  most  often  associated  with  in- 
juries of  the  cerebellum  or  disturbances  in  the  end  organs  or  nerve 
tracts  leading  to  the  cerebellum.  One  of  the  important  functions 
of  this  portion  of  tlie  brain  is  equilibration  which  requires  an 
uninterrupted  and  complete  flow  of  afferent  impulses,  especially 
from  the  cochlea,  semicircular  canals,  eye  and  muscles  of  the  body. 
When  the  end  organs  are  suddenly  thrown  out  of  function  or  the 
tracts  leading  from  them  are  interfered  with  the  cerebellum  fails 
to  receive  the  necessary  data  for  the  performance  of  its  peculiar 
function  and  the  symptoms  of  vertigo  result.  Vertigo  may  fol- 
low excessive  impulses  from  a  given  region,  as  well  as  absence  or 
diminution  of  impulses.  Thus,  irritative  lesions  of  the  semicir- 
cular canals  may  flood  the  cerebellum,  so  to  speak,  with  abnormally 
strong  or  incorrect  impulses  so  that  the  function  of  this  portion 
of  the  brain  is  disturbed.  The  conditions  in  which  such  dis- 
turbance may  occur  are  legion ;  it  may  be  present  in  mild  or  severe 
cases,  either  organic  or  functional  in  nature,  and  hence  vertigo 
is  a  common  symptom  and  is  usually  of  little  diagnostic  value.  It 
rarely  persists  however  if  there  is  no  organic  lesion  present.  It 
may  be  subjective  or  objective;  the  patient  feels  that  he  is  turn- 
ing, or  suffers  from  the  sensation  of  surrounding  objects  revolving 
about  him. 

12.  General  flaccidity  sometimes  including  sphincteric  relaxation 
is  a  condition  common  to  all  forms  of  profound  coma  and  will 
therefore  be  seen  in  the  more  severe  types  of  head  injury.  The 
more  sudden  and  violent  the  onset  of  coma  the  greater  the  prob- 
ability of  involuntary  evacuations. 

The  deep  reflexes  may  be  lost  in  coma  from  any  cause  if  the 
unconsciousness  is  extremely  profound.     They  are  absent,  there- 


422  FRACTURES   AND   DISLOCATIONS 

foi-f,   ill   lu'ad    iiijufit's   of   llic    luoiv  soverr   type.      (Sp'.'   ]M\ge  423 
for  deep  reflexes  as  a  localiziiiii;  syinptoui.) 

13.  Variaiious  hi  the  j)ulse  and  blood  prcsstirr  occur  as  already 
described  iiiulcr  coucussion  and  allied  coiiditions  (see  pa^v  407). 
Wlien  slioek  alone  is  i)resent  tlie  pulse  will  l)e  rajiid  and  the  tension 
low;  when  cerebral  compression  occurs  the  j)ressure  rises  and  the 
pulse  becomes  slow  and  lioiindinii'.  A  patient  in  exti'emis  will 
show  a  weak,  ra[)id,  ii'i-e^ulai'  i)ulse  reuardless  of  the  presence 
of  compression. 

14.  Variations  in  rcspirdlioH  are  conuuon  in  head  injuries.  Any 
profound  unconsciousness  may  be  accompanied  by  stertorous 
breathing  especially  if  the  jjci'son  occupies  the  dorsal  recumbent 
position.  It  is  common  in  deep  sleep  and  is  due  to  relaxation 
of  the  soft  palate  and  lips.  It  may  be  siuhin'^-,  lanouid,  explosive, 
irregular,  shallow,  deep,  etc.  Khythmic  disturbances  are  sometimes 
seen,  as  exemplified  in  Clieyne-Stokes '  respiration  in  which  the 
pectoral  excursion  increases  with  each  respiration  until  the  patient 
presents  the  symptoms  of  pronounced  dyspnuea,  when  the  respira- 
tory excursions  grow  progressively  weaker  until  a  condition  of 
apnoea  is  again  reached ; — after  a  short  period  of  quiescence  the 
cycle  is  repeated.  In  some  instances  irritation  of  the  respiratory 
center  produces  a  pronounced  snorting  with  each  inspiration.  The 
more  severe  cases  of  head  injury  are  often  accompanied  by  the 
more  pronounced  disturbances  in  respiration. 

15.  Variations  in  temperature  occur  commonly  in  head  injuries. 
Simple  concussion  is  accompanied  by  low'ering  of  temperature  in 
most  cases.  Laceration  of  the  brain  tissue,  contusion  and  compres- 
sion are  attended  by  rise  in  temperature  if  the  condition  is  at  all 
severe.  Variations  in  temperature  are  considered  among  the  gen- 
eral symptoms,  yet  an  extreme  elevation  of  temperature  (106°- 
109°  F.)  accompanies  pontine  lesions  and  hence  the  temperature 
becomes  a  localizing  symptom. 

Localizing  Symptoms. — The  localizing  symptom.s  occurring  in 
head  injuries  are  extremely  variable,  moreover  unconsciousness 
obscures  many  of  these  symptoms  early  in  the  condition. 

16.  Deviations  in  the  positions  of  the  eyes  are  common  and 
show  considerable  variation.  The  eye  of  the  injured  side  may  be 
turned  in  any  direction  regardless  of  the  position  of  the  opposite 
eye.  External  and  internal  strabismus  or  an  upward  turning  of 
the  eye  are  common.     Turning  of  the  head  and  both  eyes  toward 


FRACTURES   OF   THE   SKULL  423 

the  side  of  the  lesion  is  not  infrequently  found  and  is  known  as 
"conjugate  deviation."     Nystagmus  is  sometimes  observed. 

17.  Alterations  in  pupillary  reactions  and  size  usually  accompany 
fracture  of  the  base  of  the  skull.  The  most  common  disturbance  is 
that  of  dilatation  of  the  pupil  with  loss  or  diminution  in  reaction 
on  the  same  side  as  the  lesion.  The  pupil  of  the  opposite  side  is 
often  normal  in  size  and  reaction.  Pronounced  contraction  usually 
means  an  irritative  lesion  of  the  third  nerve  but  is  rarely  seen. 
Loss  of  reaction  in  one  or  both  pupils  is  a  grave  symptom.  When 
the  optic  nerve  or  tract  anterior  to  the  oculo-motor  nuclei  is  torn 
the  pupillary  reflex  is  abolished  through  destruction  of  the  afferent 
arc  of  the  reflex  arc.  Wernicke's  hemianoptic  pupillary  reaction 
may  be  present  in  cortical  visual  lesions.^ 

18.  Local  paralyses  and  disturbances  in  muscular  tone  may  be 
present  if  the  cortex  has  been  injured,  monoplegias,  hemiplegias 
or  crossed  paralyses  may  be  present  according  to  the  site  of  the 
lesion.  The  paralysis  may  be  overlooked  in  the  unconscious  state 
if  the  surgeon  is  not  observant.  If  the  cortical  lesion  is  irritative 
the  corresponding  peripheral  area  v^^ill  show  increased  muscular 
tone,  twitching  or  spasm.  When  the  pressure  becomes  sufficient 
to  throw  the  involved  area  of  the  cortex  out  of  function  paralysis 
develops.  Sensory  losses  frequently  occur  over  areas  correspond- 
ing in  extent  with  the  motor  paralysis,  the  anesthesia  usually 
preceding  the  paretic  condition. 

19.  Disparity  in  deep  reflexes. — When  paralysis  exists  in  an 
extremity  following  cortical  injuries  the  deep  reflexes  are  dimin- 
ished or  lost  throughout  the  paralyzed  area.  If  the  cortical  lesion 
is  irritative  as  indicated  by  increased  muscular  tone,  twitchings  or 
spasm,  the  deep  reflexes  in  the  member  presided  over  (i.  e.,  the  con- 


t  The  author  has  observed  an  irregularity  in  the  rotundity  of  the  pupil  in  about 
a  dozen  instances  of  fracture  of  the  posterior  fossa  with  cerebellar  injury,  though  he 
cannot  state  definitely  at  the  present  time  that  this  pupillary  peculiarity  is  necessarily 
indicative  of  cerebellar  disturbances.  Dilatation  of  the  upper  outer  quadrant  of  the 
iris  has  been  present  in  most  instances  (in  one  case  this  same  portion  of  the  iris 
showed  more  contraction  than  the  remaining  three  quarters  of  the  pupillary  circum- 
ference). The  same  irregularity,  though  much  less  pronounced,  occurs  at  times  in  al- 
coholism, and  the  oval  pupil  is  reported  as  one  of  the  symptoms  of  Gerlier's  disease. 
Alcohol  has  a  distinct  influence  on  the  cerebellum  as  is  indicated  by  the  ataxic  condi- 
tion of  drunkenness  and  the  symptoms  of  Gerlier's  disease  all  point  unmistakably  to 
cerebellar  disturbances.  The  nerve  supply  to  the  dilating  fibres  of  the  upper  outer 
quadrant  of  the  iris  are  from  a  different  portion  of  the  symjDathetic  than  those  inner- 
vating the  remainder  of  the  pupil ;  the  clinical  observations  therefore  are,  to  some  ex- 
tent, in  accordance  with  the  anatomical  facts.  Further  observation  and  experiment 
will  determine  the  value  of  the  symptom. 


424  FRACTURES   AND   DISLOCATIONS 

tralateral  half  of  face,  arm  or  leg)  will  be  exaggerated.  Thus 
an  arm  or  leg  with  an  irritative  cortical  lesion  in  the  opposite  hem- 
isphere of  the  cerebrum  will  show  an  increase  of  the  deep  reflexes 
when  compared  with  the  sound  limb.  If  the  cortical  lesion  be 
paralytic  the  deep  reflexes  will  be  less  than  those  of  the  opposite 
unaffected  member,  or  what  is  still  more  common  tlicy  will  be 
entirely  wanting  early  in  the  condition. 

20.  The  temperature  of  the  yaralyzed  litnh  will  usually  show 
a  reduction  of  one  or  one  and  a  half  degrees  below  that  of  the  op- 
posite member.  Twenty-four  to  forty-eight  hours  following  the 
injury  the  temperature  in  the  affected  member  is  likely  to  rise  a 
degree  or  so  above  normal,  being  higher  than  the  temperature 
observed  in  the  opposite  extremity.  These  surface  temperatures 
are  best  taken  by  the  surgeon  himself,  to  secure  the  most  accurate 
results.^ 

21.  Disturbance  in  the  higher  psychic  function  (judgment, 
reasoning,  concentration,  etc.)  is  sometimes  attendant  upon  lesions 
of  the  frontal  lobes.  The  disturbances  in  function  however  are  by 
no  means  constantly  proportionate  to  the  extent  and  severity  of 
the  injury.  Severe  damage  may  occur  in  the  frontal  region  with 
loss  of  brain  tissue  and  still  not  be  followed  by  any  appreciable 
disturbance  in  the  reasoning  powers  of  the  individual,  yet  injury 
in  this  region  is  at  times  attended  by  distinct  clouding  of  the 
intellect  or  disturbed  mentality.  Damage  to  the  frontal  lobes  is 
much  more  likely  to  be  followed  by  functional  impairment  in  chil- 
dren than  in  adults  and  is  probably  due  to  the  fact  that  the  injur}'' 
is  sustained  during  the  developmental  period. 

22.  Aphasias  will  seldom  be  noted  early  following  fracture  of 
the  skull  because  of  unconsciousness.  Later  on  the  patient  may 
show  auditory  aphasia,  visual  aphasia,  motor  aphasia  or  graphic 
motor  aphasia  or  any  combination  of  these  defects.  Auditory  and 
visual  aphasia  most  frequently  occur  together.  The  center  for  au- 
ditory word  memories  is  in  the  left  temporal  lobe,  that  for  visual 
word  memories  is  in  the  left  angular  gyrus,  that  for  motor  mem- 
ories is  in  the  foot  of  the  third  left  frontal  convolution,  and  the 
remaining  center  for  graphic  motor  memories  is  probably  located  in 
the  second  left  frontal  convolution  near  the  centers  for  the  right 


1  In  taking  surface  temperature  the  skin  should  be  thoroughly  dried  with  a  pledget 
of  cotton  and  the  thermometer  held  in  place  with  an  adhesive  strap  for  five  minutes 
actual  count  by  the  watch.  Alcohol  should  not  be  used  in  cleaning  and  drying  the  skin 
because  of  the  refrigerant  action  attendant  upon  evaporation. 


FRACTURES   OP   THE   SKULL  425 

hand.  In  left-handed  persons  these  speech  centers  are  located  on 
the  opposite  side.  Any  of  these  various  types  of  aphasias  may  be 
present  according  to  the  site  of  the  cortical  lesion  or  the  damage 
done  to  the  tracts  leading  to  or  from  them.  Inasmuch  as  these 
different  functions  are  all  more  or  less  interdependent  we  will 
see  the  different  types  of  aphasias  occurring  together  in  varying 
degrees  and  combinations.  The  stereognostic  sense  is  located  in 
the  parietal  lobe  and  injury  to  this  region  will  be  followed  by 
astereognosis. 

23.  Organic  lesions  and  functional  disturbances  in  the  cranial 
nerves  commonly  accompany  fracture  of  the  skull,  especially  the 
base,  and  the  symptoms  will  vary  with  the  function  of  the  nerve. 
Many  of  the  cranial  nerve  functions  are  sensory  and  therefore 
subjective  in  nature  so  that  the  symptoms  of  disturbed  or  destroyed 
function  are  not  recognizable  during  unconsciousness.  Any  of  the 
cranial  nerves  may  be  injured  in  fracture  of  the  base  or  their 
centers  may  be  irritated  or  destroyed  in  lesions  involving  the  bulb. 
The  function  of  these  nerves  may  be  disturbed  by  shock  or  by 
intracranial  pressure  without  organic  lesion  in  either  center  or 
nerve  so  that  restoration  of  function  is  complete  when  the  intra- 
cranial pressure  is  removed  or  concussion  passes  off.  Complete 
loss  of  function  usually  means  permanent  impairment;  slight  loss 
of  function  is  often  followed  by  complete  recovery.  Loss  of  func- 
tion in  some  of  the  cranial  nerves  may  come  on  some  time  follow- 
ing the  accident  especially  if  meningitis  develops.  It  is  seldom 
that  a  single  cranial  nerve  is  injured. 

I.  Consciousness  is  necessary  to  determine  the  presence  or  ab- 
sence of  smell,  hence  disturbances  in  this  sense  cannot  be  recog- 
nized early.  Fracture  of  the  anterior  fossa,  hemorrhage  between 
the  olfactory  bulb  and  the  cribriform  plate,  raising  and  tearing 
the  bulb  from  the  olfactory  nerves,  hemorrhage  within  the  bulb 
or  above  it  with  pressure,  or  thrust  wounds  through  the  nose  may 
injure  or  destroy  this  sense. 

II.  The  optic  nerve  is  sometimes  injured  in  fractures  of  the 
base.  The  cella  Turcica  seems  to  be  frequently  involved  in  frac- 
tures traversing  the  base  and  the  close  proximity  of  the  optic 
nerves,  chiasm  and  tracts  accounts  for  blindness  and  some  forms 
of  impaired  vision  which  may  follow  basal  fracture.  Injury  as 
the  nerve  passes  through  the  optic  foramen  is  probably  most  com- 
mon.    Blindness  may  be  noted  as  soon  as  the  patient  regains  con- 


426  FRACTURES   AND   DISLOCATIONS 

sciousness  and  is  due  to  hemorrhage  within  or  about  the  nerve  or 
Ulceration  of  the  nerve  itself.  Blindness  coming  on  some  time 
after  the  injury  has  been  noted  in  some  cases  of  fracture  of  the 
base  and  may  be  due  to  pressure  from  callus  formation  when  the 
fracture  passes  through  the  optic  foramen.  (See  "Alterations  in 
Pupillary  Reactions,"  page  423.) 

Ill,  IV,  and  VI.  The  third,  fourth  and  sixth  cranial  nerves 
have  long  intracranial  courses  beneath  the  brain  and  are  therefore 
especially  exposed  to  injury  in  fractures  of  the  base.  Tlie  third 
nerve  is  more  commonly  injured  in  one  of  its  brandies  than  is  the 
entire  nerve.  Paralysis  of  all  the  branches  of  the  motor  oculi  is 
followed  by  external  strabismus  and  dilatation  of  the  pupil.  The 
eyeball  assumes  different  positions  when  different  branches  of  the 
third  are  involved.  Paralysis  of  the  sixth  is  followed  by  internal 
strabismus.  Paralysis  of  the  fourth  nerve  is  more  difficult  to  recog- 
nize ;  it  may  be  accompanied  by  diplopia  or  looking  downward. 

V.  The  fifth  nerve  is  the  sensory  nerve  of  the  face,  and  in- 
nervates the  muscles  of  mastication.  Anesthesia  of  the  face  fol- 
lows injury  of  this  nerve  and  if  the  damage  is  permanent,  herpes, 
keratitis  neuroparalytiea  and  trophic  disturbances  may  follow  in 
the  skin  of  the  face.  The  motor  fibres  supplying  the  muscles  of 
mastication  travel  with  the  third  or  inferior  maxillary  divi- 
sion. 

VII.  The  seventh  supplies  all  the  muscles  of  the  face  and  the 
buccinator.  Injury  to  this  nerve  is  attended  by  the  characteristic 
symptoms  of  Bell's  palsy.  It  is  the  most  frequently  injured  of 
the  twelve  cranial  nerves. 

VIII.  The  eighth  cranial  nerve  is  the  nerve  of  hearing  and  when 
torn  across  will  be  followed  by  deafness.  Fracture  through  the 
petrous  portion  of  the  temporal  may  injure  the  organs  of  hearing 
or  clots  may  collect  within  the  tympanum  and  thus  disturb  hear- 
ing without  injury  to  the  nerve  itself.  The  bone  conduction  test 
should  be  the  only  one,  therefore,  on  which  to  base  a  diagnosis 
of  injury  to  the  nerve.  Irritation  of  the  eighth  nerve  is  likely 
to  be  accompanied  by  persistent  tinnitus  and  aural  vertigo  as  well 
as  impaired  hearing. 

IX.  X,  and  XI.  The  ninth,  tenth  and  eleventh  cranial  nerves 
have  a  short  intracranial  course  and  in  their  exit  from  the  skull 
occupy  the  middle  portion  of  the  jugular  foramen  with  the  lateral 
sinus  on  one  side  and  the  inferior  petrosal  sinus  on  the  other. 


FRACTURES   OF    THE   SKULL  427 

The  large  size  of  the  foramen  through  which  they  pass  and  their 
short  intracranial  courses  render  them  less  liable  to  injury  than 
most  other  nerves  passing  through  the  base  of  the  skull.  Their 
nuclei,  however,  situated  in  the  medulla  are  very  commonly  tem- 
porarily disturbed  in  function  by  increased  intracranial  pressure 
or  raised  blood  tension,  as  evidenced  by  the  respiratory,  cardiac 
and  gastric  disturbances  occurring  in  head  injuries.  A  traumatic 
lesion  which  seriously  injures  or  destroys  these  centers  is  usually 
immediately  fatal.  Injuries  of  the  ninth  nerve,  as  evidenced  by 
disturbances  in  swallowing,  rarely  occur  in  head  injuries.  Sen- 
sory and  motor  disturbances  in  the  larynx,  disturbances  of  the 
stomach  and  intestines,  disturbance  in  heart  action  and  respiration, 
may  accompany  injury  to  or  disturbed  function  of  the  vagus. 

The  spinal-accessory  supplies  the  sterno-mastoid  and  upper  por- 
tion of  the  trapezius  on  the  same  side  and  paralysis  of  these  two 
muscles  follows  injury  to  the   eleventh  cranial  nerve. 

XII.  The  twelfth  cranial  nerve  is  rarely  injured  in  fracture  of 
the  skull.  Paralysis  of  half  the  tongue  followed  by  trophic  changes 
in  the  paretic  side  of  the  organ  and  disturbances  in  the  innerva- 
tion of  certain  muscles  of  the  neck  are  the  symptoms. 

Diagnosis. — The  diagnosis  of  fracture  of  the  skull  may  be  so  evi- 
dent that  one  cannot  fail  to  recognize  the  condition,  but  on  the 
other  hand  the  symptoms  may,  in  some  cases,  be  so  obscured  or 
indefinite  that  it  is  impossible  to  state  whether  or  not  fracture 
exists. 

A  searching  history  and  thorough  examination  are  the  two  es- 
sentials for  proper  diagnosis. 

The  history  should  be  taken  in  systematic  order,  inquiry  with 
proper  deductions  being  made  on  the  following  points:  nature  of 
accident,  manner  in  which  injury  was  sustained  with  estimation 
of  degree  of  trauma,  onset  and  degree  of  unconsciousness  if  present, 
symptoms  displayed  prior  to  observation  by  the  surgeon.  Was 
there  spasm?  Was  there  hemorrhage  from  mouth,  nose  or  ears? 
If  blood  is  found  in  the  external  auditory  canal,  did  it  run  into 
ear  from  an  adjoining  wound  of  face  or  scalp,  or  did  it  first  ap- 
pear in  the  ear?  What  were  the  patient's  surroundings?  Was 
there  probability  of  poison  having  been  given  to,  or  taken  by  him  ? 
Did  previous  disease  exist,  such  as  nephritis  or  diabetes?  Has  he 
been  subject  to  fits  of  any  kind  ?  What  has  been  the  previous  state 
of  his  health  ?     Has  he  or  any  of  his  family  been  subject  to  nervous 


428  FRACTURES   AND    DISIjOCATIONS 

diseases  or  conditions  in  which  unconsciousness  took  place?     What 
is  his  age? 

E.rami)iaiion.—l^  patient  is  unconscious  determine  as  far  as 
possible  the  depth  of  coma,  examine  pupils,  note  reaction  to  light, 
compare  size  of  two  pupils,  and  cii'culai-ity  of  each.  Note  the 
position  of  eyes,  and  position  of  head  with  relation  to  position  of' 
eyes,  note  motility  of  eyeballs,  examine  for  paralyses  or  spasm  of 
extremities  or  face.  Compare  deep  reflexes  of  two  sides,  test  for 
Babinski's  sign,  patella  clonus,  ankle  cloiuis.  Observe  general 
muscular  tone  and  coiulition  of  skin,  variations  in  pulse  and  blood 
pressure,  abnormalities  in  respiration.  Compare  temperature  of 
tAvo  sides.  Examine  scalp  carefully  for  evidences  of  trauma;  if 
wounds  of  the  scalp  or  hematomata  are  present  they  should  be 
explored  and  enlarged  if  necessary,  wdth  due  precaution  for  asep- 
sis. The  scalp  should  be  shaved  and  the  wound  treated  as  de- 
scribed previously  under  the  heading  of  scalp  wounds.  Cranial 
sutures  should  not  be  mistaken  for  linear  fractures  while  inspect- 
ing the  bottom  of  the  wound,  and  rents  in  the  pericranium  ^should 
not  be  confused  with  depression,  Avhen  palpation  is  employed. 
Use  probe  rarely,  wdth  caution  and  only  after  sterilization  in  flame. 
Determine  mobility  and  crepitus  when  present.  Note  nature  and 
amount  of  fluids  escaping  from  one  or  both  ears.  Pure  blood  or 
blood  mixed  with  serum,  liquor  Cotunii,  or  cerebrospinal  fluid  may 
escape  from  the  ear,  nose,  or  mouth.  It  would  seem  an  easy  mat- 
ter to  recognize  cerebrospinal  fluid  when  mixed  with  blood,  but  the 
condition  seems  to  have  been  simulated  by  large  quantities  of 
serum  or  liquor  Cotunii,  and  it  is  often  a  difficult  matter  to  state 
definitely  that  a  given  fluid  escaping  from  the  skull  contains  cere- 
brospinal fluid.  When,  however,  the  fluid  is  watery,  low  in  al- 
bumin and  high  in  sodium  chlorid  one  may  feel  reasonably  sure 
that  cerebrospinal  fluid  is  present.  The  face  and  scalp  should 
be  examined  for  ecchymosis  and  emphysema.  Ecchymosis  about 
the  eye  wdth  adjoining  bruise  or  abrasion  of  the  face  is  indicative 
only  of  superficial  injury.  Ecchymosis  about  the  eye  spreading 
toward  the  external  canthus  from  the  inner  angle  and  accompanied 
by  conjunctival  ecchymosis  and  no  proximate  trauma  of  the  face 
is  indicative  of  fracture  of  the  base,  the  blood  coming  from  within 
the  orbit. 

A  chart  should  be  kept  and  the  symptoms  entered  in  the  order  of 
their  appearance.     Special  note  should  be  made  of  the  tempera- 


FRACTURES   OF    THE   SKULL  420 

ture,  respiration,  pulse,  blood  pressure  and  depth  of  unconscious- 
ness. Early  unconsciousness  is  usually  the  result  of  concussion, 
prolonged  unconsciousness  is  suggestive  of  contusion,  laceration 
or  compression.  A  return  to  the  unconscious  state  is  almost  al- 
ways due  to  intracranial  hemorrhage.  Rise  of  blood  pressure  with 
slow  pulse  usually  indicates  hemorrhage.  Palpation  alone  is  too 
inaccurate  to  be  dependable  in  determining  the  blood  pressure; 
we  should  use  the  sphygmomanometer.  Before  drawing  conclu- 
sions on  the  blood  pressure  we  should  know  the  condition  of  the 
arteries  and  the  age  of  the  patient,  at  least  approximately.  For 
example:  a  tension  of  170  m.m.  in  a  man  of  sixty  with  arterio- 
sclerosis would  not  be  as  indicative  of  hemorrhage  as  the  same 
pressure  in  a  man  of  twenty-five  with  normal  elastic  arter- 
ies. 

Albumin  and  sugar  may  make  their  appearance  in  the  urine  a 
short  time  following  head  injuries  and  for  this  reason  the  patient 
should  be  catheterized  at  the  earliest  possible  moment  and  the 
urine  analyzed  to  determine  the  condition  of  the  urine  excreted 
prior  to  the  accident.  This  urinalysis  when  compared  with  later 
tests  may  indicate  the  source  of  sugar  or  albumin  when  present. 
The  value  of  localizing  symptoms  in  diagnosis  will  best  be  appre- 
ciated by  reviewing  these  symptoms  on  page  412. 

A  careful  consideration  of  the  facts  disclosed  in  the  history  and 
determined  by  examination  will  in  most  cases  afford  sufficient  data 
for  a  correct  diagnosis.  Many  of  the  symptoms  of  fracture  which 
are  of  value  are  subjective  in  nature  or  appear  late  in  the  course 
of  the  case  and  are  not  available  at  the  usual  time  of  the  first  ex- 
amination. 

Differential  Diagnosis. — Fracture  of  the  skull  with  brain  injury 
is  usually  associated  with  a  more  or  less  complete  loss  of  conscious- 
ness and  it  will  be  necessary  in  avoiding  mistakes  to  exclude  other 
forms  of  coma.  A  mistaken  diagnosis  may  deprive  the  patient 
of  a  much  needed  decompressive  operation  or  may  subject  him  to 
dangerous  surgical  procedure  when  the  coma  is  due  to  toxic  or 
other  conditions  not  amenable  to  surgery.  It  will  therefore  be 
necessary  to  consider  other  forms  of  unconsciousness  that  we  may 
systematically  exclude  them  before  making  a  diagnosis  of  brain 
injury.  The  following  classification,  like  most  classifications,  is 
by  no  means  ideal,  yet  it  will  form  a  working  basis  on  which  to 
consider  the  causes  of  coma. 


430  FRACTURES    AND    DISLOCATIONS 

A.  Coma  due  to  temporary  cireiilatory  disturbance. 

1.  Syncope. 

2.  siioek.- 

'A.   Cerebi'al    eon^^c'stioii. 

4.  Cerebi'al   anemia. 

B.  Coma    due    to    medieinal    and    oilier    extraneous    poisons    cir- 

culatiuii'  in   the  blood. 

5.  Ak'oliolie  coma. 

6.  Opium  coma. 

7.  Phenol    coma. 

8.  Chloral  eoma. 

9.  Asphyxia  from  illuminatiiio-  oas. 

10.  Asphyxia  from   eai'bon   monoxid. 

11.  Ptomaine  coma. 

12.  Lead  coma. 

13.  Belladonna  and   its  alkaloids. 

14.  Hyocyamus  and  its  alkaloids. 

C.  Coma   following   chronic   disease   and   due   to   toxins   arisins: 

within    the    body. 

15.  Uremic  coma. 

16.  Diabetic  coma. 

D.  Reflex    comas    and    those   precedins;   or    following   acute    in- 

fections. 

17.  Convulsions  and  coma  sometimes  precede  the  acute  exan- 

themata in  childhood. 

18.  Reflex  convulsions  and  coma  may  accompany  dentitional 

and    gastro-intestinal   disturbances   in    children. 

19.  Comatose  conditions  may  accompany  acute  infections  sucli 

as  typhoid,  pneumonia,   etc. 

E.  Diseases  and  neuroses  of  the  central  nervous  system  are  not 

infrequently  accompanied  by  coma. 

20.  Hysteria  and   feigning. 

21.  Epilepsy. 

22.  Apoplex3^ 

Cerebral  hemorrhage. 
Cerebral  embolism. 
Cerebral  thrombosis. 


FRACTURES    OF    THE   SKULL  481 

23.  Cerebral  syphilis. 

24.  Cerebral  meningitis. 

25.  Abscess  of  brain. 

26.  Tumor  of  brain. 

27.  Epileptiform   and   apoplectiform   attack's   diu'   to   ccrcbi'Hl 

arterial  disease. 

A.  Coma  Due  to  Temporary  Circulatory  Disturbance. — 
1.  Syncope. — The  essential  of  syncope  is  the  fact  that  it  is  tran- 
sient; lowering-  of  the  head  or  shock,  such  as  is  produced  by  cold 
water,  is  accompanied  by  the  return  of  consciousness  within  a 
few  minutes.  Pallor  of  the  skin  and  mucous  membranes,  with 
cold,  clammy,  relaxed  skin  are  constant ;  pupils  are  equal  and 
dilated,  with  reaction  to  light  sluggish  or  absent;  pulse  weak, 
rapid  and  sometimes  perceptible  only  in  the  larger  vessels ;  tem- 
perature subnormal;  respiration  weak,  shallow  and  quiet.  The 
characteristic  symptoms  of  other  forms  of  coma  are  absent.  In 
simple  syncope,  not  due  to  organic  heart  disease,  the  attack  is 
evanescent.  Disease  of  the  heart  or  vessels  may  produce  an  un- 
consciousness more  profound  and  prolonged  in  character,  with  a 
tendency  toward  cyanosis.  Hysterical  syncope  is  likely  to  be  re- 
peated; it  lacks  the  essential  symptoms  of  simple  syncope.  The 
color  of  the  skin  and  mucous  membranes  and  the  pulse  are  un- 
changed, unless  the  attack  is  accompanied  by  severe  muscular  exer- 
tion, as  seen  in  hysterical  convulsions. 

2.  Shock. — Shock  and  cerebral  concussion  are  so  closely  asso- 
ciated that,  for  practical  purposes,  it  is  useless  to  distinguish 
closely  between  them.  Shock  is  a  condition  accompanying  cere- 
bral concussion  though  it  may  occur  independently  of  it,  as  seen 
following  hemorrhage.  In  the  milder  forms  of  shock  conscious- 
ness may  be  practically  undisturbed,  while  in  severer  forms  coma 
is  often  profound.  Pulse  is  weak,  rapid,  often  irregular  and  some- 
times slow;  respiration  .shallow,  frequent  and  usually  quiet;  the 
functional  activities  of  the  entire  body  are  lessened ;  the  tempera- 
ture falls  below  normal  early  in  the  condition  §ind  the  blood 
pressure  may  be  markedly  reduced.  The  symptoms  usuallj^  last 
for  a  few  hours ;  recovery  is  the  rule  except  in  the  severer  forms. 
Vomiting  frequently  occurs  as  the  patient  is  regaining  conscious- 
ness. Interruption  in  recovery,  prolonged  or  delayed  shock  or  an 
increase  in  the  symptoms  after  the  first  few  hours  usually  indicates 


432  FRACTURES   AND   DISLOCATIONS 

serious    complications.      In    simple    shock    or    concussion    localizing 
symptoms  are  absent. 

3.  Ccrchral  con(i(  sfi<ni. — The  most  common  cause  of  congestion 
of  the  brain  is  isolation.  The  onset  of  coma  is  usually  gradual  and 
preceded  by  headache  and  dcliriuin.  The  arterial  tension  is  high; 
pulse  rapid,  full  and  stronu ;  respiration  often  rapid,  deep  and 
noisy;  temperature  usually  a  dciiree  or  two  above  normal.  The 
history  of  exposure  to  a  toirid  sun,  absence  of  trauma,  and  local 
and  localizing  symptoms  diri'ci'ciiliato  the  condition  from  brain 
injury. 

4.  Cerchral  anemia. — Aside  from  syncope  and  shock  anemia  of 
the  brain  is  commonly  the  result  of  exsanguination.  The  diagnosis 
is  made  on  the  history  of  loss  of  blood  and  the  symptoms,  which 
resemble  shock.  Any  degree  of  loss  of  consciousness  may  be  pres- 
ent from  slight  lethargy  to  deep  coma.  Delirium  and  convulsions 
may  occur  when  the  hemorrhage  has  been  sudden  and  profuse. 

B.  Coma  Due  to  Medicinal  and  Other  Extraneous  Poisons 
Circulating  in  the  Blood. — Unconsciousness  resulting  from  acute 
poisoning  has  alwa^^s  been  a  source  of  diflficulty  in  diagnosing  un- 
conscious states  due  to  head  injury.  Simple  drunkenness  is  prob- 
ably the  most  common  cause  of  abnormal  unconsciousness  and  the 
frequency  with  which  this  condition  is  seen,  together  with  the  pre- 
disposition these  cases  show  to  accidental  injury,  makes  the  subject 
an  important  one.  Persons  attempting  suicide  not  infrequently 
take  more  than  one  poison  to  accomplish  the  result  or  may  combine 
poison  with  self-inflicted  injury,  such  as  cutting  the  throat  or 
jumping  from  a  window.  The  diagnosis  under  such  conditions  is 
rendered  more  ditBcult  and  accordingly  the  surgeon  should  not  be 
satisfied  as  soon  as  a  single  cause  of  unconsciousness  is  found. 
Of  one  hundred  consecutive  poison  cases  treated  by  the  author 
thirty-four  were  due  to  opinm  or  morphine,  twenty  to  phenol,  nine 
to  alcohol,  seven  to  ptomaine,  six  to  chloroform,  four  to  strychnine, 
four  to  chloral,  three  to  biehlorid  of  mercury,  two  to  illuminating 
gas,  three  were  complicated  by  hysteria,  in  four  the  nature  of  the 
poison  was  unknown  and  in  nineteen  cases  the  poison  was  unusual 
and  has  been  classified  under  the  heading  "miscellaneous."  Deep 
coma  was  present  in  thirty-six  of  the  hundred  cases,  death  resulted 
almost  immediately  in  five  cases  and  in  thirteen  instances  the  cause 
of  poisoning  or  coma  was  multiple.  Simple  eases  of  alcoholism 
were  not  included  among  these  cases  except  as  a  complication  of 


FRACTURES   OF    THE   SKULL  433 

some  other  poison  or  unless  the  case  presented  serious  symptoms. 
Simple  cases  of  hysteria  are  also  excluded  except  as  a  complica- 
tion of  poison.  In  the  majority  of  these  cases,  by  close  examina- 
tion of  the  patient's  surroundings  or  by  inquiry  from  those 
present,  it  was  possible  to  determine  the  nature  of  the  poison  in- 
gested, independently  of  the  symptoms  presented  by  the  case. 
These  figures  indicate  to  some  extent  the  difficulty  sometimes  ex- 
perienced in  determining  the  cause  of  unconsciousness  and  illus- 
trate the  necessity  of  being  familiar  with  the  symptoms  occurring 
in  the  various  forms  of  poisoning.  In  this  respect  we  have  to  con- 
sider not  only  the  most  frequent  forms  of  poisoning  but  those  most 
frequently  producing  a  comatose  condition  which  might  be  mistaken 
for  the  unconsciousness  following  head  injury. 

5.  Alcoholic  coma. — The  condition  is  so  common  that  the  symp- 
toms are  usually  recognized  without  difficulty  as  being  due  to 
alcohol.  The  symptoms  however  are  so  similar  to  the  general 
symptoms  occurring  in  head  injury  that  it  is  sometimes  only  by  the 
most  careful  and  persistent  observation  that  the  existence  of  the 
two  conditions  may  be  recognized  when  they  occur  together.  There 
are  two  types  of  alcoholic  coma  which  deserve  mention;  the  first 
is  the  acute  type  occurring  in  persons  not  habitually  accustomed  to 
the  use  of  alcohol  and  the  second  is  that  of  acute  drunkenness  in 
a  chronic  drunkard.  In  the  first  we  have  simply  the  acute  effects 
of  the  drug,  taken  in  over-dose,  while  in  the  second  we  have  the 
acute  effects  of  the  drug  added  to  the  condition  of  chronic  alco- 
holism. The  generally  unkempt  condition,  bloated  face,  chronic- 
ally inflamed  eyes,  reddened  nose,  putty-like  complexion  with  edema 
beneath  the  lower  eyelids  (usually  indicating  chronic  nephritis) 
all  point  to  chronic  alcoholism.  This  appearance  gives  the  exam- 
iner a  portion  of  the  history  of  the  case  at  a  glance.  The  depth 
of  coma  varies  in  acute  alcoholism  according  to  the  amount  of  al- 
cohol ingested.  It  is  usually  possible  to  rouse  the  patient  by  sud- 
denly producing  pain  such  as  may  be  inflicted  by  supraorbital 
pressure,  by  pressure  behind  the  ramus  of  the  jaw,  by  pressing  a 
lead  pencil  into  the  web  of  the  fingers  or  by  means  of  the  electric 
brush.  When  aroused  he  is  usually  noisy  and  abusive  until  the 
annoyance  is  removed,  when  he  lapses  back  into  his  drunken  sleep 
or  stupor.  If  he  can  be  made  to  talk,  even  if  only  a  little,  the 
characteristic  thick  speech  of  alcoholism  is  recognized.  Some- 
times the  coma  is  extremely  profound  so  that  it  is  not  possible  to 


434  FRACTURES   AND   DISLOCATIONS 

rouse  him  by  any  ordinary  means  and  we  are  obliged  to  resort  to 
the  electric  brush.  Repeated  stimuli  will  often  produce  results 
when  a  single  application  of  the  brush  or  of  supraorbital  pres- 
sure would  elicit  no  response.  Alcohol  may  be  detected  on  the 
patient's  breath.  The  clean  fresh  breath  of  simple  acute  alcohol- 
ism is  quite  different  from  the  characteristically  foul  and  offensive 
odor  emanating  from  the  mouth  of  a  chronic  drunkard.  The  pu- 
pils are  usually  equal,  slightly  dilated  and  respond  sluggishly  to 
light,  though  they  may  be  either  moderately  contracted  or  dilated. 
The  temperature  is  usually  normal,  unless  he  has  been  exposed  to 
weather  as  frequently  occurs  in  drunkenness.  The  pulse  is  as  a 
rule  increased  sliglitly  in  rate  and  low  in  volume.  Slight  cyanosis 
commonly  occurs  about  the  face  and  neck.  The  respiration  is 
often  blowing  or  stertorous.  The  skin  is  relaxed  and  covered  with 
cold  sweat.  The  deep  reflexes  are  present  though  reduced.  The 
appearance  of  the  patient,  alcoholic  breath,  condition  of  the  pupils, 
respiration,  temperature,  pulse  and  nature  of  the  coma  together 
with  the  absence  of  local  and  localizing  symptoms  will  usually  serve 
to  differentiate  alcoholic  coma  from  brain  injury.  Another  fre- 
quent form  of  unconsciousness  (to  be  taken  up  later  on  page  443) 
is  that  of  apoplectiform  and  epileptiform  convulsions  (commonly 
spoken  of  as  ''whiskey  fits"),  which  occur  in  advanced  cases  of 
chronic  alcoholism. 

6.  Opium  coma. — Opium  or  its  alkaloids  is  one  of  the  common 
methods  of  suicide,  and  the  length  of  time  between  ingestion  and 
coma  is  ample,  even  when  large  doses  are  taken,  to  permit  the  pa- 
tient already  bent  on  self-destruction  to  meet  with  accident.  The 
condition  due  to  opium  poisoning  is  characteristic ;  the  pulse  is 
slow,  usually  weak;  respiration  extremely  slow^  (5  or  6  to  the  min- 
ute), usually  noisy  from  the  relaxed  condition  of  the  soft  palate 
and  lips;  temperature  generally  normal,  though  it  may  be  slightly 
subnormal  and  may  rise  preceding  dissolution.  Pupils  are  strongly 
contracted  and  usually  show  little  or  no  tendency  to  react  to  light. 
Inquiry  into  the  surroundings  of  the  case  will  generally  disclose 
the  cause  of  the  coma  in  the  form  of  an  empty  labeled  vial  or  box. 
The  history  of  the  case,  the  characteristic  symptom-complex,  the 
absence  of  local  and  localizing  symptoms  will  readily  differentiate 
the  condition  from  brain  injury. 

7.  Phenol  coma. — Poisoning  from  carbolic  acid,  especially  large 


FRACTURES   OF    THE   SKULL  435 

doses,  produces  unconsciousness  within  a  short  time  of  ingestion. 
The  skin  is  pale,  cold,  clammy  and  relaxed ;  respiration  stertorous ; 
pulse  weak  and  rapid;  temperature  may  be  subnormal;  pupils 
usually  equal,  dilated  and  either  sluggish  or  rigid.  The  character- 
istic white  eschar  of  carbolic  acid  is  seen  about  the  lips  and  within 
the  mouth,  and  the  characteristic  odor  of  the  poison  permeates  the 
room. 

8.  Chloral  coma. — The  most  characteristic  symptom  of  poison- 
ing from  chloral  is  the  early  and  pronounced  cyanosis  which 
usually  precedes  loss  of  consciousness.  When  coma  develops  it 
rapidly  becomes  profound ;  the  temperature  is  lowered  from  one  or 
two  to  several  degrees  below  normal ;  the  pulse  is  at  first  soft  and 
slow,  becoming  rapid  and  irregnilar  as  the  patient  passes  into  a  more 
critical  state;  the  pupils  are  moderately  contracted  early  in  the 
condition,  becoming  dilated  as  the  coma  becomes  more  profound. 
The  patient  is  thoroughly  relaxed  and  the  respiration  is  slow. 
The  functions  of  the  entire  body  are  greatly  depressed.  The  pro- 
nounced lividity,  deep  coma,  muscular  relaxation  and  the  absence 
of  local  and  localizing  symptoms  serve  to  differentiate  the  condition 
from  brain  injury. 

9.  Asphyxia  from  illuminating  gas. — The  patient  smells  strongly 
of  the  gas.  During  the  coma  the  respiration  is  slow  and  blowy, 
pulse  slow  and  weak,  pupils  sluggish  but  reactive  to  light  until 
shortly  before  death.  Temperature  subnormal.  The  history  of 
the  case  or  the  odor  of  gas  emanating  from  the  patient  will  be 
sufficient  to  determine  the  cause  of  unconsciousness. 

10.  Asphyxia  from  carbon  monoxid. — In  poisoning  from  carbon 
monoxid  the  clinical  picture  is  quite  different  from  asphyxia  re- 
sulting from  illuminating  gas.  The  patient  is  rigid  and  tremors 
pass  over  the  body,  there  is  slight  cyanosis  and  frequently  a  light 
froth  at  the  mouth.  Eespiration  labored,  pulse  weak  and  irreg- 
ular. The  eyes  are  sometimes  open  and  the  patient  may  roll 
them  about  giving  the  impression  of  consciousness,  when  in  reality 
he  knows  nothing  of  his  surroundings.  Vomiting  is  common  and 
on  analysis  of  the  vomitus,  carbon  monoxid  is  found.  Skin  relaxed 
and  covered  with  cold  perspiration.  The  history  of  the  case  hav- 
ing been  exposed  to  carbon  monoxid  and  the  peculiar  symptoms 
will  determine  the  diagnosis. 

11.  Ptomaine  poisoning. — In  poisoning  by  ptomaines  the  onset 


436  FRACTURES   AND   DISLOCATIONS 

is  gr;ulual,  arconipaiiied  by  severe  gastro-intestinal  disturbances. 
Coma  is  not  common  and  is  late  in  development.  The  history  alone 
should  serve   to   ditl'erentiate  the   condition. 

12.  Coma  from  hod  'poisoning  occurs  specially  in  those  persons 
whose  occupation  exposes  them  to  the  fumes  of  the  metal.  The 
onset  of  coma  is  gradual  and  preceded  by  convulsions,  colic,  purg- 
ing and  vomiting.  The  presence  of  lead  in  the  urine  and  the  blue 
line  on  the  gums  will  distinguish  the  condition  from  otiier  forms 
of  coma  even  if  no  history  is  obtainable. 

13.  Coma  from  belladonna  is  often  preceded  by  convulsions  and 
delirium.  The  temperature  is  raised,  respiration  slow  and  deep 
until  the  patient  is  in  extremis,  pulse  rapid.  Pupils  are  widely 
dilated,  skin  hot  and  dry  and  covered  with  the  characteristic  rash 
produced  by  the  drug. 

14.  Hyocyamus  and  its  allaloids  dilate  the  pupil  though  not  as 
Avidely  or  quickly  as  belladonna.  Extreme  dryness  of  the  mouth 
and  tliroat  is  present,  with  flushed  face.  The  pulse  and  respira- 
tion are  slow  and  the  temperature  may  show  a  rise  though  the 
diaphoresis  produced  by  the  drug  would  tend  to  reduce  this  again. 
Incoordination  is  present  before  the  patient  loses  consciousness 
and  later  on  pronounced  muscular  relaxation  is  present. 

C.  Coma  Following  Chronic  Disease  and  Due  to  Toxins 
Arising  Within  the  Body. — Nephritis  and  diabetes  are  two  con- 
ditions which  we  should  never  fail  to  consider  when  examining 
unconscious  cases.  The  enfeebled  condition  which  these  two  dis- 
eases often  produce  predispose  the  sufferer,  especially  in  cities,  to 
accident.  But,  on  the  other  hand,  the  fact  that  albumin  or  sugar 
is  found  in  the  urine  of  an  unconscious  case  should  not  cause  us 
to  jump  at  the  conclusion  that  the  cause  of  coma  is  necessarily  the 
unconsciousness  produced  by  the  disease.  Other  forms  of  un- 
consciousness should  be  excluded  as  far  as  possible,  the  patient 
carefully  watched  for  further  developments,  and  the  proper  treat- 
ment for  diabetic  or  uremic  coma  instituted. 

15.  Uremic  coma. — Uremic  coma  is  usually  of  gradual  onset,  be- 
ing often  preceded  by  headache  and  malaise.  Delirium  and  con- 
vulsions are  usually  present  preceding  absolute  unconsciousness. 
Albumin  and  tube  casts  are  found  in  the  urine  but  their  presence 
aside  from  a  history  of  nephritis  or  other  symptoms  of  the  disease 
is  of  little  diagnostic  value  since  they  occur  so  frequently  in  injury 


FRACTURES   OF    THE   SKUI.L  487 

and  diseases  of  the  brain  and  other  conditions.  If  the  disease  has 
advanced  far  enough  to  produce  coma,  we  are  almost  sure  to  find 
other  symptoms  of  the  disease  such  as  edema  of  the  legs,  edema 
beneath  the  eyes,  the  facies  peculiar  to  chronic  nephritis  and  the 
characteristic  urinous  odor  to  the  breath.  Uremia  may  simulate 
the  symptoms  of  brain  injury  more  closely  than  any  other  condi- 
tion. Variations  of  the  pupils,  apparent  paralysis  of  the  extrem- 
ities or  of  one  side  of  the  face,  ocular  deviations,  or  conjugate 
deviation  of  the  head  and  eyes  not  infrequently  occur  and  may 
lead  one,  especially  if  wounds  or  abrasions  of  the  scalp  exist,  into 
making  a  diagnosis  of  intracranial  hemorrhage  or  brain  injury 
when  the  symptoms  are  due  entirely  to  uremia.  These  symptoms, 
however,  are  found  to  change  in  character  and  position  (a  sup- 
posed paralysis  shifting  from  one  member  to  another)  which  is  not 
the  case  in  organic  lesions  of  the  brain.  A  careful  history  of  the 
case,  the  lack  of  permanency  in  the  false  localizing  symptoms  and 
the  presence  of  other  evidences  of  advanced  nephritis  will  usually 
suffice  in  making  the  differential  diagnosis. 

16.  Diabetic  coma. — In  coma  due  to  diabetes  the  onset  is  vari- 
able; it  may  come  on  rapidly  following  exertion  or  it  may  be 
gradual  and  preceded  by  nausea  and  vomiting.  Sugar  in  large 
quantities  is  found  in  the  urine  though  this  is  by  no  means  pathog- 
nomonic. It  is  one  thing  to  determine  that  the  patient  has  dia- 
betes and  quite  another  to  prove  that  the  unconsciousness  is  a 
direct  result  of  the  disease.  Acetones  are  of  more  value  in  diag- 
nosis than  in  sugar.  The  blood  picture  in  diabetes  is  often  typ- 
ical ;  hyperglycemia  and  polycythemia  are  usually  present. 
Moderate  leukocytosis  and  beta-oxybutyric  acid  are  almost  con- 
stant in  diabetic  coma.  A  high  percentage  of  fat  is  often  found 
in  the  blood  and  the  red  corpuscles  fail  to  take  the  stain  as  in 
normal  blood.  Boils  or  carbuncles,  or  scars  indicating  their  pre- 
vious existence,  are  sometimes  found  on  the  skin.  The  harsh  dry 
skin,  sometimes  showing  diabetic  bronzing,  localized  gangrene  as- 
sociated with  arteriosclerosis,  onychia,  etc.,  when  present  suggest 
diabetes.  The  breath  often  has  a  peculiar  sweet,  heavy  odor,  char- 
acteristic of  diabetes.  The  history  of  the  case,  examination  of  the 
blood  and  urine,  and  the  presence  of  some  of  the  symptoms  of 
diabetes  above  mentioned  will  usually  disclose  the  cause  of  the 
coma.     In   examining  the  blood  of  these  cases  it  is  essential  to 


438  FRACTURES   AND   DISLOCATIONS 

(li-aw  olV  a  sutticient  (|uaiitity  (8  or  10  c.c\)  to  oiiablc  the  laboratory 
man  to  conduct  a  satisfactory^  chemical  and  microscopical  exam- 
ination. 

D.  Reflex  Comas  and  Those  Preceding  or  Following  Acute 
Infections. 

17.  The  acute  exanthemata  of  childhood  arc  sometimes  usliered 
in  by  couvidsions  and  coma.  This  is  particularly  true  of  scarlet 
fever.  The  eruption  of  scarlet  fever  makes  its  appearance  \\illiin 
twenty-four  hours,  following  which  the  coma  passes  ott'.  The  tem- 
perature in  the  preemptive  stage  is  usually  high  (104  or  105). 
It  is  often  impossible  to  make  a  positive  diagnosis  before  the  erup- 
tion makes  its  appearance,  yet  by  inquiring  into  the  history  of 
exposure  to  infection  and  the  absence  of  cranial  trauma  together 
with  the  history  of  one  or  two  convulsions  followed  by  coma  and 
high  temperature  should  lead  us  to  suspect  an  acute  infection. 

18.  Coma  due  to  dentitional  or  gastrointestinal  disturbances  in 
children  will  usually  give  a  history  pointing  to  these  disorders 
prior  to  the  onset  of  unconsciousness.  Coma  is  usually  preceded 
by  convulsions.  The  temperature  is  lower  and  the  pulse  slower 
than  usually  found  preceding  the  acute  exanthemata. 

19.  Comatose  states  developing  during  acute  infections  usually 
come  on  late  in  the  course  of  the  disease  and  in  most  cases  the  pre- 
ceding history  will  be  all  that  is  necessary  for  differentiation. 
The  low  muttering  delirium  of  typhoid  and  similar  conditions  is 
too  characteristic  to  be  mistaken. 

E.  Diseases  and  Neurosks  of  the  Central  Nervous  System 
ARE  NOT  Infrequently  Accompanied  by  Coma  and  it  is  often 
difficult  to  determine  whether  the  patient  fell  unconscious  because 
of  the  disease  or  whether  unconsciousness  is  the  result  of  head  in- 
jury sustained  in  an  accidental  fall. 

20.  The  com,a  of  hysteria  usually  occurs  in  women,  comes  on 
rapidly  and  may  be  preceded  or  alternate  with  delirium.  The  pa- 
tient frequently  falls  with  the  onset  of  unconsciousness,  but  it  will 
be  noted,  usually  falls  in  a  convenient  place  and  is  not  injured  in 
the  act.  The  pulse  respiration  and  temperature  are  normal  ex- 
cept in  instances  in  which  there  has  been  severe  muscular  exertion 
such  as  occurs  in  hysteria  major.  In  such  cases  the  respiration 
may  be  rapid  but  is  free  and  not  stertorous,  and  the  temperature 
may  show  a  degree  or  so  of  elevation  with  a  slightly  accelerated 
pulse.     When  the  examiner  raises  the  eyelid  for  inspection,  the 


FRACTTIRKS   OP    TITK    SKULL  439 

eyeball  presents  a  characteristic  rolling  movement,  with  at1(;mpt  on 
the  part  of  the  patient  to  keep  the  pupil  under  cover  of  tlie  margin 
of  the  lid.  Muscular  resistance  from  the  orbicularis  palpebrarum 
is  also  encountered  in  raising  the  eyelid.  The  pupils  are  usually 
normal  and  react  to  light;  muscular  exertion,  however,  may  cause 
them  to  be  slightly  dilated.  Suddenly  inflicted  pain  will  usually 
elicit  prompt  response  and  often  results  in  the  surgeon  being 
roundly  scored  for  his  trouble.  In  rare  instances  however  the 
patient  will  withstand  the  most  severe  supra-orbital  pressure,  re- 
sponding only  with  the  use  of  the  electric  brush.  Evacuations  of 
the  bladder  or  bowel  never  occur  in  hysterical  coma. 

A  clever  malingerer  may  simulate  any  form  of  coma  but  for- 
tunately those  who  attempt  feigning  are  usually  not  well  enough 
versed  in  symptomatology  to  produce  a  consistent  picture.  The 
eyeball  is  never  fixed  in  the  malingerer  and  the  pupil  reacts  nor- 
mally to  light.  Sudden  and  repeated  pain  will  elicit  response  as 
in  hysteria.  Convulsions  and  rigidity  are  much  less  common  than 
in  hysteria. 

The  exhibition  of  apomorphine  will  cause  the  hysteric  or  feigner 
to  forget  about  his  unconsciousness  as  soon  as  he  becomes  actively 
engaged  with  the  effects  of  the  drug.  Other  causes  of  unconscious- 
ness may  readily  be  excluded  by  the  absence  of  the  symptoms  which 
accompany  real  coma  and  the  fact  that  the  patient  can  be  com- 
pletely roused. 

21.  Unconsciousness  due  to  epilepsy. — The  ordinary  epileptic  fit 
is  of  short  duration,  in  fact  the  surgeon  seldom  arrives  on  the  scene 
in  time  to  witness  the  attack.  If  the  history  of  the  case  can  be 
had  or  the  onset  of  the  attack  is  observed  there  will  be  little  diffi- 
culty in  differentiating  the  condition  from  other  causes  of  coma. 
The  patient  often  presents  a  semicomatose  condition  following  the 
attack  or  may  show  delirium  or  become  activel}^  maniacal.  The 
tongue  is  often  bitten  during  an  attack  and  in  manj^  cases  old 
scars  are  present  on  the  tongue  indicating  injury  to  the  organ  in 
previous  convulsions.  In  old  cases  of  epilepsy  it  is  common  to 
find  numerous  old  scars  on  the  scalp  and  face,  the  result  of  injuries 
sustained  in  previous  attacks.  The  history  of  the  case,  the  short 
duration  of  the  unconsciousness  and  the  absence  of  localizing  symp- 
toms will  distinguish  the  condition  from  other  forms  of  coma.  In 
status  epilepticus,  however,  one  attack  follows  so  closely  upon  an- 
other that  unconsciousness  is  continuous  and  it  may  be  almost  ira- 


440  FRACTURES   AND   DISLOCATIONS 

possible  witliout  tlie  history  of  the  ease  to  difiPerentiate  between 
this  condition  and  an  acute  cerc])ral  lesion.  It  should  be  remem- 
bered, in  this  connection,  that  intraci-anial  hemorrhage  may  result 
from  an  epileptic  attack  and  the  niainicr  in  whicli  these  eases  fall 
may  produce  fracture  of  the  skull  or  meningeal  hemorrhage. 

22.  .Ipo/)/^. /■//.— Differentiation  between  apoplex}-  and  traumatic 
brain  injui-y  may  under  some  circumstances  be  extremely  difficult. 
The  history  of  the  case  should  be  inquired  into  most  carefully 
with  special  reference  to  the  manner  in  which  coma  developed. 
Apoplexy  is  one  form  of  brain  injury  and  hence  the  symptoms  will 
be  similar  to  those  occurring  as  a  result  of  brain  injury  from 
external  trauma.  When  the  cortex  is  irritated,  as  occurs  in  men- 
ingeal hemorrhage  or  pressure  from  fragments,  the  paralysis  is 
more  likely  to  be  preceded  by  local  spasm ; — when  the  damage 
is  done  to  the  tracts  leading  from  the  cortex  as  is  usual  in  apo- 
plexy, the  paralytic  symptoms  are  preceded  by  only  slight  spasm 
if  convulsive  movements  are  present  at  all.  The  local  symptoms 
of  brain  injury  should  be  carefully  looked  for  and  excluded  if 
there  is  any  question  as  to  the  cause  or  site  of  the  hemorrhage. 

Cerebral  embolism,  thrombosis  and  hemorrhage  are  included 
under  the  heading  of  apoplexy,  yet  the  three  conditions  are  so 
different  in  some  respects  that  their  characteristics  will  have  to 
be  considered  separately.  Cerehral  embolism  is  seen  oftenest  be- 
tween the  ages  of  thirty  and  fifty,  occurs  during  physical  activity 
or  when  strain  is  thrown  upon  the  heart  from  any  cause.  A 
previous  history  of  articular  rheumatism  or  chorea  complicated  by 
cardiac  disease  is  usually  obtainable.  If  the  heart  is  auscultated 
murmurs  will  usually  be  noted,  since  the  condition  is  most  often 
the  result  of  vegetative  endocarditis  involving  the  mitral  valve. 
The  onset  of  coma  is  very  sudden,  being  caused,  as  a  rule,  by 
occlusion  of  the  middle  cerebral  artery.  The  lesion  may  be  irrita- 
tive or  paralytic  with  corresponding  motor  increase  or  motor 
loss.  The  cerebral  edema  surrounding  the  area  of  anemia  usually 
clears  up  within  a  few  days,  with  corresponding  diminution  in  the 
extent  of  the  symptoms.  The  only  part  of  the  brain  suffering 
permanent  damage  is  that  portion  previously  supplied  by  the 
occluded  artery.  Abscess  or  softening  frequently  follows.  The 
previous  history  of  the  case,  the  presence  of  endocarditis,  the  onset 
of  coma,  and  the  absence  of  cranial  trauma  will  usually  be  suffi- 
cient to  differentiate. 


FRACTURES   OF    THE   SKULL  441 

Cerebral  thrombosis  occurs  most  frequently  between  the  aj^es  of 
twenty  and  forty  or  after  sixty-five.  When  it  occurs  between 
twenty  and  forty  it  is  usually  due  to  syphilis,  and  other  symptoms 
of  this  disease  will  be  present.  Other  debilitating  conditions  how- 
ever may  be  responsible  for  thrombosis,  such  as  tuberculosis,  can- 
cer, primary  anemia,  hemorrhage,  diabetes  and  pregnancy.  When 
thrombosis  takes  place  after  sixty-five  it  is  almost  invariably  due 
to  arteriosclerosis.  It  usually  occurs  during  sleep  or  similar  states 
of  inactivity  in  which  the  blood  pressure  is  lowered  or  the  viscosity 
of  the  blood  increased.  The  history  usually  shows  previous  at- 
tacks of  dizziness  or  periods  of  weakness  or  paresthesia  in  an  ex- 
tremity lasting  a  few  hours  or  days.  The  onset  of  coma  is,  as  a 
rule,  gradual  and  progressive  and  since  the  pathologic  process  most 
frequently  occurs  in  the  cortical  veins  the  symptoms  are  at  first 
irritative  in  character.  Aside  from  weakness,  the  common  aura 
consist  of  attacks  of  vertigo,  aphasia,  local  peripheral  muscular 
twitchings  or  spasm,  or  disturbances  in  sight.  The  lesion  produces 
more  damage  than  takes  place  in  embolism  and  the  symptoms  in- 
dicate progress  as  the  thrombus  extends  in  the  vessel,  including 
additional  branches.  In  some  instances  the  thrombus  may  extend 
around  under  the  base  of  the  brain  involving  centers  of  the  op- 
posite side.  Thrombosis  in  the  aged  is  a  frequent  source  of  cere- 
bral softening;  abscess  is  relatively  rare.  The  gradual  onset  of 
unconsciousness,  progressive  nature  of  the  localizing  symptoms, 
lowered  blood  pressure,  and  the  previous  history  of  the  case 
should  differentiate  the  condition  from  traumatic  head  injury. 

Cerebral  hemorrhage  most  often  occurs  between  the  ages  of 
forty  and  sixty.  It  may  take  place  prior  to  forty  in  persons  suf- 
fering from  premature  arteriosclerosis  or  in  conditions  which 
predispose  to  arterial  disease  or  sudden  elevation  of  blood  pressure. 
The  onset  is,  as  a  rule,  sudden  and  the  cerebral  damage  is  done  at 
once ;  the  usual  seat  is  the  lenticulo-striate  artery  with  accompany- 
ing injury  to  the  internal  capsule  which  results  in  a  hemiplegie 
syndrome.  If  the  hemorrhage  is  sufficient  to  break  into  and  flood 
the  ventricles  the  symptoms  will  be  bilateral  from  the  first  and 
usually  terminate  fatally.  In  the  common  form  of  cerebral  hemor- 
rhage the  patient  falls  as  if  struck  down,  and  becomes  rapidly  un- 
conscious with  turgescence  of  the  face  and  neck.  Hemiplegia, 
variations  in  respiration,  flaccidity,  sphincteric  disturbances  and 
conjugate  deviation,  are  some  of  the  symptoms  which  may  occur 


442  FRACTURES   AND   DISLOCATIONS 

ill  l)()tli  apoplfxy  and  iVactiii-e  of  the  skull  \vitli  cortical  pressure, 
so  that  it-  is  impossible  in  some  cases  to  distinguish  between  the 
two  conditions"  b}^  the  general  and  localizing  symptoms  alone. 
The  similarity  in  the  localizing  symptoms  of  the  two  conditions  is 
due  to  the  similarity  in  the  lesions.  In  apoplexy  however  the 
paralysis  is  more  likely  to  involve  the  entire  side  (i.  e.,  hemiplegia) 
because  of  the  small  territory  occui)ied  by  the  fibres  as  tliey  pass 
through  the  internal  capsule;  in  fracture  of  the  skull  it  would 
require  an  unusuall}'  large  clot  or  area  of  depressed  l)one  to  in- 
clude all  the  cortical  centers  for  the  entire  opposite  side  of  the 
body.  In  apoplexy  the  extent  and  degree  of  paralysis  rarely  in- 
crease, because  the  damage  to  the  internal  capsule  is  comi)leted 
at  the  time  of  the  stroke ;  in  meningeal  hemorrhage  it  is  not  un- 
common to  see  the  region  of  paralysis  extend  and  become  more 
pronounced  as  the  clot  grows  larger,  involves  more  centers  and 
produces  greater  pressure.  Monoplegias  therefore  are  more  com- 
mon in  cortical  lesions  than  in  cerebral  hemorrhage.  IMonoplegic 
forms  of  cerebral  hemorrhage  however  are  sometimes  seen  in  in- 
stances in  which  some  small  artery  other  than  the  lenticulo-striate 
is  ruptured  producing  paretic  or  irritative  symptoms  according 
to  the  seat  of  hemorrhage.  The  ingravescent  form  of  cerebral 
hemorrhage  is  extremely  rare,  the  symptoms  are  gradual  and  pro- 
gressive in  onset,   and   it  usually  terminates  within   a   few  days. 

The  similarity  in  the  two  conditions  may  be  extremely  confusing 
at  times,  especially  if  an  apoplectic  has  sustained  a  scalp  wound  or 
other  head  injury  in  the  fall  accompanying  the  stroke.  IMost 
careful  incpiiry  should  be  made  into  the  history  of  the  case  and 
the  onset  of  unconsciousness.  A  careful  examination  of  the  head 
for  the  local  symptoms  of  fracture  of  the  skull  will  often  clear 
the  diagnosis  in  doubtful  cases.  Fracture  of  the  skull  with  local- 
izing symptoms  usually  shows  more  pronounced  and  earlier  pupil- 
lary inequalities  than  occur  in  cerebral  hemorrhage. 

23.  Cerebral  syphilis  usually  occurs  between  the  ages  of  twenty- 
five  and  fifty.  AVhen  coma  develops  in  the  course  of  this  disease 
it  is  usually  slowly  progressive  and  not  deep  at  the  onset.  Severe 
headache,  especially  during  the  afternoon  and  evening,  pain  in 
tlie  shin  bones,  monocular  palsies  and  the  symptoms  of  cerebral 
thrombosis  above  referred  to  commonly  precede  loss  of  conscious- 
ness. Other  symptoms  of  syphilis  are  likely  to  be  present  if  the 
coma  is  due  to  this  disease.     In  some  instances  a  definite  history 


FRACTURES   OF   THE   SKULL  443 

of  specific  infection  is  obtainable  but  on  tlie  other  hand  the  de- 
termination of  syphilis  should  not  lead  us  to  consider  this  the  cause 
of  coma  without  a  thorough  examination  for  and  exclusion  of  frac- 
ture of  the  skull,  especially  in  cases  which  are  known  to  have  met 
with  accident.  In  doubtful  cases  the  Wassermann  blood-test  should 
be  made. 

24.  Cerebral  meningitis. — It  is  uncommon  for  cerebral  menin- 
gitis and  cerebral  trauma  to  be  associated  or  confused.  Acute 
cerebral  meningitis  is  usually  caused  by  the  pneumococcus, 
"Weichelbaum 's  meningococcus,  or  occurs  as  a  part  of  other  acute 
infectious  processes  especially  in  childhood.  The  history  of  the 
disease  preceding  unconsciousness  is  almost  invariably  obtainable. 
Headache,  vertigo,  chills  or  general  convulsions  precede  the  rapidly 
deepening  coma.  Rigidity  of  the  neck  muscles  with  retraction  of 
the  head  is  present  and  if  the  patient  is  not  absolutely  uncon- 
scious, motion  of  the  head  will  be  resisted  and  cause  him  to  cry 
out.  Opisthotonos  develops  when  the  spinal  membranes  become 
involved.  The  temperature  is  usually  raised  though  it  may  be 
subnormal  from  the  onset.  The  pulse  is  slow  and  irregular  and 
the  respiration  increased.  Unilateral  convulsions  may  occur.  The 
leukocyte  count  is  high.  Lumbar  puncture  is  of  great  value  in 
diagnosis.  The  history  of  the  case,  characteristic  symptoms,  and 
absence  of  head  trauma  will  usually  render  the  diagnosis  easy. 

25.  Abscess  of  the  brain. — Abscess  of  the  brain  may  occur  at 
any  age.  Two-fifths  of  the  cases  are  the  result  of  suppurative 
otitis  media ;  suppurative  processes  within  the  chest  are  responsible 
for  a  large  proportion  of  the  remaining  three-fifths.  The  usual 
early  symptoms  resemble  those  of  embolism.  The  middle  stage  of 
cerebral  abscess  is  quiescent.  The  third  stage  develops  when  rup- 
ture occurs.  Absolute  coma  occurs  late  and  is  gradual  in  onset 
except  when  it  accompanies  rupture  and  then  the  symptoms  simu- 
late those  occurring  in  both  meningitis  and  cerebral  hemorrhage. 

26.  Tumor  of  the  brain. — The  history  shows  headache,  cerebral 
vomiting,  choked  disc,  and  a  slow  pulse.  The  onset  of  coma  is 
slow.  When  the  history  can  be  obtained  the  condition  should 
never  be  mistaken  for  brain  trauma. 

27.  Apoplectiform  and  epileptiform  convulsions  occur  chiefly  in 
arterial  diseases  of  the  brain  such  as  seen  in  alcoholism,  uremia, 
paretic  dementia,  tumor  of  the  brain  and  disseminated  sclerosis. 
The  most  common  form  is  that  occurring  in  chronic  alcoholism. 


444  FRACTURES   AND   DISLOCATIONS 

The  essentials  of  the  condition  are  the  convulsions  followed  by 
coma,  in  some  cases,  with  symptoms  which  at  first  appear  as  local- 
izing- symptoms  but  are  evanescent  in  character.  The  history  of 
previous  disease  and  the  transitory  character  of  the  symptoms 
will  render  the  diagnosis  easy. 

Treatment. — Each  case  must  be  considered  by  itself,  with  special 
reference  to  tlie  different  symptoms  displayed.  For  example:  a 
given  case  may  show  a  scalp  wound  and  bony  depression  in  the 
region  of  the  middle  meningeal  artery  with  profuse  and  dangerous 
hemorrhage,  so  that  operation  with  elevation  of  the  fragments  and 
hemostasis  is  the  prime  requisite  of  ti-eatment.  Another  case  may 
show  the  most  profound  shock  without  signs  of  increased  intra- 
cranial pressure,  the  condition  being  such  that  the  added  physio- 
logical insult  of  operation  could  have  only  a  fatal  outcome  if 
jierformed  before  reaction  takes  place.  In  this  type  of  case  stimu- 
lation is  indicated  regardless  of  localizing  symptoms  in  order  that 
the  patient  may  regain  sufficient  resistance  to  withstand  the  neces- 
sary surgical  procedure.  Still  another  case  may  show  but  little 
shock  and  only  semiconsciousness,  with  symptoms  of  increasing 
intracranial  pressure  and  paralysis  indicating  the  region  of  cortical 
damage.  Under  such  circumstances  expectant  treatment  might 
soon  see  the  patient  in  such  a  state  of  collapse  that  operation  would 
be  useless,  or  if  this  did  not  occur  the  chances  of  complete  cortical 
recovery  might  be  reduced  with  every  hour  of  delay.  The  most 
seasoned  surgical  judgment  and  acumen  are  necessary  to  deter- 
mine when  to  operate  and  when  to  leave  the  patient  surgically 
alone.  In  the  treatment  of  fracture  of  the  skull  we  must  keep 
in  mind  the  unfavorable  late  symptoms  and  sequelae  which  so  often 
follow  head  injuries,  especially  when  unoperated. 

If  the  condition  of  the  patient  does  not  call  for  immediate  op- 
eration he  should  be  put  to  bed  and  measures  instituted  for  the 
alleviation  of  shock.  Hot  water  bottles  or  some  other  form  of 
artificial  heat  is  essential  in  the  treatment,  but  the  greatest  care 
should  be  exercised  to  avoid  burning  the  patient,  since  with  un- 
consciousness the  protective  pain  and  temperature  sense  is  absent. 
The  patient  may  be  wrapped  in  blankets  previously  warmed  by 
the  fire.  The  electric  heat  blanket  is  of  great  advantage,  but  is 
usually  available  only  in  hospitals.  It  is  essential  that  a  chart  be 
begun  a.s  soon  as  possible ;  it  should  contain  records  of  the  pulse, 
respiration  and  temperature   at   frequent  and   regular  intervals; 


FRACTURES    OF    THE    SKULL  445 

pupillary  changes  and  alterations  in  the  depth  of  unconsciousness, 
especially  a  return  to  the  unconscious  state  after  a  lucid  interval, 
should  be  noted.  If  general  or  local  spasms  occur  they  should  be 
entered,  and  when  the  necessary  apparatus  is  at  hand  records  of 
the  blood  pressure  should  be  made  every  hour  or  every  two  hours 
until  the  necessity  of  operative  intervention  is  determined.  Tho 
need  of  intelligent  and  competent  observation  and  nursing  is  too 
apparent  to  require  special  mention. 

No  hard  and  fast  rule  can  be  laid  down  as  to  the  use  of  stimu- 
lants and  sedatives ;  it  will  be  necessary  to  watch  the  patient  care- 
fully and  use  drugs  as  indicated.  Strychnine  sulphate  is  a 
valuable  stimulant  but  must  be  used  with  due  regard  for  the  pos- 
sible harm  it  may  accomplish  in  intracranial  hemorrhage.  In 
some  cases  the  collapse  may  be  so  critical  that  stimulation  is  de- 
manded to  avert  death,  even  though  there  are  indications  of 
increased  intracranial  tension.  In  such  instances  stimulation  may 
render  operation  possible,  thus  affording  the  surgeon  opportunity 
for  the  removal  of  meningeal  clot.  Nitroglycerine,  in  some  cases, 
will  minimize  the  danger  which  may  accompany  the  use  of  strych- 
nine. Pain  or  extreme  restlessness  may  call  for  the  exhibition  of 
opium,  though  it  is  usually  unwise  to  use  this  drug  in  head  in- 
juries, especially  before  the  diagnosis  is  properly  established.  We 
may  otherwise  obscure  symptoms  of  the  greatest  importance ;  thus 
a  return  to  the  unconscious  state,  a  most  significant  happening, 
might  not  be  recognized  if  the  patient  had  just  previously  received 
a  hypodermic  injection  of  morphine.  Bromides,  chloral  and 
codeine  are  at  times  useful.  In  cases  of  suspected  fracture  or 
those  in  which  the  fracture  is  diagnosed  but  operation  is  not 
deemed  advisable,  the  patient  should  be  kept  at  rest  in  bed  for 
at  least  ten  days  and  carefully  watched  for  untoward  symptoms. 
A  chart  should  be  kept,  as  previously  described,  for  the  purpose 
of  accurately  determining  the  course  the  case  is  taking.  Absolute 
rest  and  quiet  are  essential.  If  the  patient  is  unconscious  suffi- 
ciently long  to  allow  the  bladder  to  become  distended  the  catheter 
should  be  used  at  regular  intervals. 

Fracture  of  the  skull  may  be  rendered  compound  by  scalp 
wounds  or  by  the  line  of  fracture  in  the  base  establishing  com- 
munication with  the  nasal  or  oral  cavities,  or  bj^  involvement  of 
the  petrous  portion  of  the  temporal,  and  when  such  is  the  case 
measures  should  be  instituted  to  prevent,  as  far  as  possible,  the 


446  FRACTURES   AND    DISLOCATIONS 

passa2:e  of  iiit'rction  ffoiii  these  cavities  to  tlie  meninges,  and  no 
form  of  treatment  is  permissible  whieli  jx-oduees  an  increased 
pressure    (eitlier  tluid  or  gaseous)    within  these  cavities. 

The  Ear. — Discharges  of  blood  or  serum  fi'om  the  ear  call  for 
a  loose,  copious  gauze  dressing  whirh  will  a])S()ib  the  thiids  as  fast 
as  they  come  from  the  external  auditory  canal.  Tlic  common 
practice  of  douching  the  canal  with  antiseptics  is  pernicious,  since 
by  this  means  infection  is  more  often  carried  inward  than  is  steri- 
lization accomi>lish('d.  The  canal  should  uot  be  plugged  with 
cotton,  as  commonly  i)racticed,  since  this  can  onl}^  tend  to  dam 
the  fluids  hack  instead  of  allowing  their  free  and  prompt  escape. 
If  clots  of  blood  form  within  the  external  auditory  meatus  they 
should  be  removed  wdth  a  sterile  ear-hook  so  that  the  canal  may 
be  kept  open.  Fracture  of  the  base,  allowing  the  escape  of  blood 
within  the  cranium  or  into  the  petrous  portion  of  the  temporal, 
is  much  more  favorable  in  outlook  if  this  blood  makes  its  escape 
through  the  ear. 

The  nppcr  part  of  the  nasal  cavity  and  of  the  naso-pharynx  are 
sometimes  the  seat  of  basal  fractures  w^hich  establish  communi- 
cation between  these  cavities  and  the  meninges.  When  such  is  the 
case,  as  commonly  indicated  by  hemorrhage  or  the  escape  of 
cerebrospinal  fluid,  the  nose  and  mouth  should  receive  the  most 
careful  attention.  The  nose  should  be  kept  free  and  clean  by  the 
removal  of  clots  forming  in  the  lower  part  of  the  nose.  Alkaline 
washes,  Avhen  properly  used,  may  facilitate  the  removal  of  these 
clots,  but  violent  douchings  or  syringings  should  be  avoided,  lest 
they  carry  infection  into  or  through  the  line  of  fracture.  For 
similar  reasons  the  patient  should  not  be  allowed  to  blow  his  nose, 
and  if  coughing  occurs  it  must  be  controlled  by  sedatives.  Scre- 
atus  will  draw  the  secretions  through  the  posterior  nares  and, 
since  it  is  accompanied  by  the  same  result,  a  negative  air  pressure 
within  the  nasal  cavities  is  to  be  recommended  instead  of  blowing 
the  nose.  Hemorrhage  from  the  nose,  unless  severe,  does  not  call 
for  checking,  and  plugging  of  the  nostrils  only  results  in  the 
accumulation  of  foul  and  infectious  clots  within  the  nasal  cavities. 
The  mouth  should  be  frequently  washed  out  and  the  teeth  cleansed 
with  potassium  chlorate  tooth  paste.  The  cleansing  and  treatment 
of  scalp  wounds  has  already  been  described ;  when  fissures  or  de- 
pressions exist  at  the  bottom  of  the  wound  irrigation  is  contra- 
indicated. 


FRACTURES   OF    THE   SKULL  447 

Operative  Treatment. — Operative  treatment  is  called  for; — in 
the  treatment  of  scalp  wounds,  for  the  elevation  of  depressed  frag- 
ments in  either  simple  or  compound  fracture  of  the  vault,  for 
alleviation  of  meningeal  hemorrhage,  for  the  removal  of  foreign 
bodies  within  the  skull,  for  the  correction  of  secondary  complica- 
tions such  as  cortical  irritation  resulting  from  old  scars,  and  for 
the  treatment  of  tumors,  abscesses  or  softening.  In  depression  of 
the  vault  it  is  often  possible  to  elevate  and  remove  the  fragments 
with  a  heavy  rat-tooth  forceps;  but  in  other  instances  it  may  be 
necessary  to  trephine  on  the  solid  side  of  one  of  the  margins  of 
the  depression,  to  introduce  an  elevator  beneath  the  fragments.     A 


533.  Fig.    534. 


Fig.  533. — Diagram  indicating  the  steps  in  opening  the  skull  by  means  of  an 
osteoplastic  flap.  1,  2,  3  and  4  indicate  the  positions  of  trephine  openings.  Solid 
lines  indicate  division  of  skull.  Line  3-4  indicates  where  the  flap  is  turned  back. 
Dotted   line   indicates    skin   incision. 

Fig.   534. — Shows  the  motor  area  exposed  when  the  flap  is  turned  back. 

simple  fissure  without  localizing  symptoms  or  indications  of  intra- 
cranial pressure  does  not  necessarily  call  for  opening  of  the  skull, 
but  in  many  cases  the  safest  plan  will  be  the  exclusion  of  menin- 
geal complication  by  operative  intervention.  Of  the  various  meth- 
ods, however,  which  have  been  employed  for  the  removal  of  a 
meningeal  clot,  the  osteoplastic  flap  is  the  most  satisfactory.  It  is 
often  difficult  to  accurately  determine  the  site  of  the  hemorrhage, 
even  when  localizing  symptoms  are  present,  and  if  an  opening  in 
the  skull  no  larger  than  that  produced  by  the  ordinary  trephine  is 
made,  the  chances  of  failure  in  locating  the  clot  are  many.  The 
change  in  recent  years  from  simple  trephining  to  the  use  of  the 


448  FRACTURES   AND   DISLOCATIONS 

osteoplastii'  flap  has  malorially  rod\UH'(l  the  percentage  of  operative 
failures.  In  niakinu-  an  osteoplastic  flap  a  U-shaped  incision  with 
tlie  convexity  iipwanl  is  made  thronsih  the  scalp  and  down  to  the 
bone,  the  sknll  is  exposed  and  two  small  trephine  openings  are 
made  at  the  npper  angles  of  the  qnadrilateral  section  of  bone  to 
be  displaced.     A   grooved  diiector  is  then  introdnccd  into  one  of 


Fig.   535. — DeVilbiss   bone-cutting   forceps    used    in   making    the    osteoplastic    flap   of 
skull  and  scalp. 

the  openings  and  passed  between  the  dnra  and  tlie  sknll  in  tlie 
direction  of  the  opening  in  the  adjoining  angle ;  by  this  means 
a  Gigli  wire  saw  is  passed  from  one  opening  to  the  other  and  the 
bone  betAveen  the  two  cnt  with  the  divider  in  place  to  protect  the 
meninges.  If  the  upper  border  of  the  bone  flap  is  beveled  at 
the  expense  of  the  inner  table,  while  being  cut  with  the  saw,  it 
will  prevent  subsequent  inward  displacement.     The  vertical  sides 


Fig.  536. — Small  trephine  employed  in  making  an  osteoplastic  flap.  The  open- 
ing made  with  this  instrument  may  be  used  to  introduce  the  Gigli  saw,  or  a  bone- 
cutting  forceps  such  as  the  DeVilbiss  may  be  used.      (See  Fig.   535.) 

of  the  bone  flap  are  then  made  by  cutting  the  skull  with  DeVilbiss 
forceps,  beginning  at  the  trephine  openings.  After  the  three  sides 
are  completed  the  base  is  broken  and  the  flap  turned  back.  The 
DeVilbiss  cutting  forceps  may  be  used  instead  of  the  saw  in  con- 
necting the  trephine  openings,  the  bone  having  been  previously 
separated  from  the  underlying  dura.     Those  skilled  in  the  use  of 


FRACTURES   OF    THE    SKULL  449 

the  chisel  and  mallet  divide  the  bone  with  considerable  facility, 
though  this  procedure  is  not  to  be  recommended  because  of  the 
shock  so  commonly  produced  by  the  hammering.  (For  the  course 
of  the  middle  meningeal  artery  and  common  sites  of  meningf^al 
hemorrhage,  see  "Surgical  Anatomy,"  page  396.)  After  the  flap 
has  been  made  and  turned  back  the  clot  should  be  removed  witli 
the  least  possible  trauma  to  the  underlying  brain.  The  artery 
from  which  the  hemorrhage  occurred  is  to  be  secured  and  ligated. 
Subdural  clots  or  bleeding  may  be  present,  necessitating  the  open- 
ing of  the  dura  to  reach  the  collection  of  blood.  In  closing  the 
wound  the  dural  edges  should  be  carefully  approximated  witli  fine 
suture  material  after  all  hemorrhage  has  been  properly  controlled. 
In  cases  of  marked  increased  intracranial  tension  it  may  be  im- 
possible to  bring  the  edges  of  the  dura  together,  or  if  such  is  done, 
the  object  of  the  operation  is  to  some  extent  defeated,  if  it  has 
been  performed  for  decompression.  In  such  instances  the  dural 
defect  may  be  provided  for  by  the  transplantation  of  a  section  of 
fascia  lata.  This  prevents  adhesions  between  the  brain  and  scalp 
and  at  the  same  time  allows  an  increase  in  intracranial  capacity 
Plastic  sliding  operations  on  the  scalp  may  be  performed  when  the 
osteoplastic  flap  cannot  be  brought  back  into  accurate  apposition 
because  of  extrusion  of  the  brain  and  dura.  Lumbar  puncture 
will  facilitate  closure  of  the  scalp  and  skull  in  an  otherwise  diffi- 
cult case  and  is  attended  by  less  danger  if  the  skull  is  open  at 
the  time  the  cerebrospinal  fluid  is  withdrawn.  Gushing 's  cross- 
bow incision  may  be  employed  in  opening  the  posterior  fossa, 
though  the  results  of  decompressive  operations  in  this  region  have 
not  been  as  satisfactory  as  one  might  wish.  The  positions  of  the 
sinuses  in  this  part  of  the  skull  must  be  kept  in  mind  when  op- 
erating in  this  region. 

Prognosis.- — The  prognosis  of  head  injuries  is  as  varied  as  the 
subject  itself.  The  outlook  will  depend  largely  upon  the  damage 
sustained  by  the  cranial  contents  at  the  time  of  the  accident  and, 
inasmuch  as  it  is  sometimes  most  difficult  to  determine  the  extent 
and  severity  of  this  damage,  it  will  be  proportionately  hard  to 
state  just  what  the  outcome  may  be.  In  addition  to  the  traumatic 
elements  we  will  have  to  consider  the  chances  of  infection  and 
meningitis  when  the  fracture  is  compound.  It  is  next  to  impossi- 
ble to  state  in  a  given  case  whether  or  not  the  patient  will  in  the 
future  develop  traumatic  epilepsy,  suffer  from  chronic  headache. 


450  FRACTURES   AND   DISLOCATIONS 

vertiiiO  and  otlici-  late  syiiiptoius.  oi'  that  lie  will  or  will  not  develop 
cerebral  tumor,  abscess,  gumma  or  softening.  In  a  general  way 
it  may  be  stated  that  the  more  severe  the  trauma,  and  the  more 
pronounced  tlu^  symptoms,  the  greater  the  danger  of  an  early, 
fatal  termination.  The  prognosis  as  to  life  is  good  in  cases  which 
survive  the  fir.st  forty-eight  hours  following  the  injury.  Rigidity 
of  the  pupils,  especially  in  dilatation,  is  conunonly  followed  by 
death,  rronounced  disturbances  in  respiration,  temperature  and 
jnUse  whether  early  or  late  in  the  case,  render  the  prognosis  grave. 
The  mortality  and  the  development  of  sequela;  have  been  materi- 
ally reduced  by  operation  in  selected  cases.  Fracture  of  the  base 
more  often  produces  death  than  fracture  of  the  vault.  Of  frac- 
tures of  the  base  those  involving  the  posterior  fossa  have  the  high- 
est mortality,  those  of  the  anterior  fossa  the  lowest,  while  fracture.s 
of  the  middle  fossa  occupy  an  intermediate  place.  This  difference 
in  mortality  is  largely  due  to  the  positions  of  the  important  basal 
ganglia,  and  to  the  fact  that  hemorrhage  into  the  anterior  or  mid- 
dle fossa^  usually  makes  its  escape  without  difficulty  through  the 
mouth,  nose  or  ears.  IMeningitis  more  commonly  follows  fracture 
of  the  anterior  and  middle  fossae,  though  the  dangers  from  this 
complication  by  no  means  equal  the  deadly  effect  of  pent-up  hem- 
orrhage within  the  posterior  fossa.  The  development  of  new  and 
significant  symptoms  during  the  course  of  the  case  may  so  alter 
the  general  aspect  in  diagnosis,  treatment  and  prognosis  that  it 
will  be  unwase  for  the  surgeon  to  make  any  definite  forecast  early 
in  the  condition.  A  most  valuable  aid  in  prognosis  will  be  found 
in  a  carefully  kept  and  complete  chart  which  points  accurately  to 
changes  occurring  in  the  case  and  shows  whether  the  symptoms  are 
increasing  in  severity,  or,  on  the  other  hand,  are  becoming  less 
pronounced. 

Late  Symptoms  and  Sequelae  Following  Head  Injuries. — The 
immediate  recovery  and  the  after-effects  in  fracture  of  the  skull 
do  not  bear  any  constant  relation  to  each  other,  nor  are  the  late 
conditions  developing  in  the  course  of  the  case  necessarily  propor- 
tionate to  the  extent  and  severity  of  the  original  damage. 

The  symptoms  of  tumor,  gumma  or  abscess  of  the  brain  may 
make  their  appearance  months  or  even  years  after  the  original 
injury,  following  an  interval  of  apparent  recovery.  In  other  in- 
stances the  symptoms  of  the  sequelae  may  develop  before  the  pa- 


FRACTURES   OF    THE   SKUI.L  451 

tient  has  recovered  from  the  acute  condition  of  fracture  of  the 
skull. 

The  unfortunate  condition  of  some  of  these  patients  is  known 
to  those  who  have  attended  large  clinics  for  any  considerable 
period.  The  head  pains,  epileptic  convulsions,  subjective  sensory 
disturbances,  psychic  changes  or  paresthesis  often  unfit  the  sufferer 
for  the  sociologic  demands  of  his  surroundings,  and  he  haunts  the 
clinics  or  passes  from  one  surgeon  to  another  with  the  persistent 
hope  that  some  new  operation  or  different  type  of  surgical  pro- 
cedure may  afford  him  relief.  The  peculiar  way  in  which  these 
patients  attempt  to  figure  out  the  details  of  intracranial  derange- 
ment and  their  fixed  opinions  concerning  the  manner  in  which  the 
surgeon  should  correct  the  trouble,  are  often  characteristic.  Epi- 
lepsy following  fracture  of  the  skull  is  not  uncommon  and  often 
assumes  the  Jacksonian  type.  When  the  convulsions  are  focal  in 
character  and  have  not  been  allowed  to  persist  for  a  period  of 
more  than  two  years  the  .chances  of  recovery,  as  a  result  of  op- 
erative intervention,  are  good  if  the  causative  cortical  irritation 
is  corrected  or  the  area  of  the  cortex  in  which  the  convulsion 
begins,  is  removed.  When  the  non-focal  form  of  epilepsy  follows 
fracture  of  the  skull  it  is  not  so  easily  controlled,  the  treatment 
being,  as  a  rule,  medical. 

Chronic  headache  often  begins  in,  or  is  confined  to,  the  region 
of  the  original  injury  and  may  be  dependent  upon  cortical  irri- 
tation. When  such  is  the  case,  operations  for  its  relief  may  be 
successful,  as  in  focal  epilepsy.  In  other  instances  the  headache 
is  general  and  the  outlook  for  surgical  relief  is  not  so  hopeful. 
Pain  in  the  nerves  of  the  scalp,  which  is  sometimes  produced  by 
cicatricial  contraction,  or  pain  in  some  of  the  cranial  nerves,  as 
a  result  of  injury,  is  not,  strictly  speaking,  headache,  and  should 
be  dealt  with  according  to  the  peculiarities  of  the  individual  case. 
Chronic  headaches  following  fracture  of  the  skull  deserve  the  most 
careful  neurological  study  in  order  that  the  cause  may  be  deter- 
mined, when  possible,  and  relief  afforded. 

Vomiting,  vertigo,  and  disturbances  in  hearing  are  sometimes 
persistent  and  extremely  distressing  to  the  patient.  Little  in  the 
way  of  radical  treatment  can  be  accomplished  for  these  conditions ; 
sedatives,  depressants  and  proper  hygienic  surroundings  are  about 
all  that  can  be  done  for  their  relief,  with  the  hope  that  they  will 


452  FRACTURES   AND   DISLOCATIONS 

ill  tiiiif  lessen  in  degree  and  finally  disappear.  When  tliese  symp- 
toms occur  as  a  result  of  cerebral  abscess,  tumor  or  softiMiing,  the 
treatment  becomes  that  of  the  causative  lesion.  Psycliic  ciianges 
are  not  infrequently  observed  following  fractures  of  tlie  skull, 
particulai'ly  in  injury  to  the  frontal  lo])es.  The  extent  of  the 
frontal  lobes,  however,  and  the  variability  in  the  proportion  exist- 
ing between  lesion  and  symptoms  renders  the  subject  of  localiza- 
tion extremely  difficult  unless  local  symptoms  exist  pointing  to  the 
exact  region  of  damage,  and  even  in  instances  in  which  a  visible 
depression  on  the  forehead  indicates  the  site  of  fracture  and  corti- 
cal displacement,  the  results  of  operation  are  by  no  means  uni- 
formly satisfactory. 

The  patient  may  show  a  simple  weakness  of  intellect,  the  com- 
prehension being  dull  and  slow,  or  he  may  present  an  irritability 
and  temperamental  change  entirely  foreign  to  his  disposition  prior 
to  the  accident.  Lassitude  and  aversion  to  either  physical  or 
mental  activity  are  common  among  the  psychic  changes.  It  not 
uncommonly  happens  that  the  patient  is  persistently  possessed  of 
abnormal  fears  and  apprehensions  regarding  his  physical  welfare, 
domestic  relations  or  business  responsibilities.  The  fear  of  failure 
is  sometimes  such  an  obsession  that  the  patient  refuses  to  even 
attempt  anything  in  the  way  of  resuming  his  former  occupation. 
It  should  not  be  understood  that  such  fears  are  without  any  real 
foundation  in  fact,  yet  when  they  do  exist  it  is  usually  noted  that 
the  real  degree  of  unfitness  is  by  no  means  proportionate  to  his 
own  sense  of  incapacity.     In  rare  instances  insanity  may  follow. 


CHAPTER  XXXII. 

FRACTURES  OF  THE  STERNUM. 

Surgical  Anatomy. — The  sternum  is  rarely  fractured.  Firstly, 
because  of  the  protection  afforded  by  the  arms  in  case  of  accident, 
and  secondly,  because  of  its  situation  and  structure.  It  is  composed 
of  a  soft,  spongy  tissue  encased  in  a  layer  of  compact  bone,  and  is 
supported  by  the  ribs  and  costal  cartilages  which  act  as  a  series  of 
springs  which  absorb  and  modify  shock. 

The  sternum  is  usually  ossified  from  six  centers ;  one  each,  for  the 
manubrium  and  ensiform  appendix,   and  four  for   the   gladiolus. 


Fig.   537. — The   sternum.      M..  manubrium;    X.,  xyphoid   cartilage;    C,   clavicle.      The 
costal  cartilages  are  numbered  in  order. 

Considerable  variation  occurs  in  the  ossification  of  this  bone.  The 
lower  sections  of  the  gladiolus  are  not  uncommonly  ossified  by  two 
centers  for  each  segment,  and  in  anomalous  instances  lack  of  fusion 
between  these  lateral  centers  may  result  in  a  foramen  or  fissure  in 
the  lower  part  of  the  second  portion  of  the  sternum,  even  in  adult 
life.     This  condition  might  be  mistaken  for  a  fracture  if  one  is  not 

453 


454  FRACTURES    A XI)    DISLOCATIONS 

aeqiiaiiited  Avitli  the  anomaly.  'Vhv  centers  of  cssitieation  in  tlu' 
sternum  make  their  appearance  in  order  from  above  downward,  the 
lirst  being  seenas  early  as  tlie  fifth  fojtal  month,  while  the  center  for 
the  lower  segment  of  the  gladiolus  is  often  not  present  until  the 
second  year.  The  center  for  the  xyphoid  cartilage  may  make  its 
appearance  anywhere  between  the  second  and  eighteenth  years. 
Fusion  of  the  different  segments  of  the  sternum  begins  at  about 
puberty  in  the  lower  end  of  the  gladiolus,  and  proceeds  upward  until 
the  process  is  completed  at  about  the  twenty-fifth  year.  The 
xyphoid  joins  the  gladiolus  at  about  forty.  The  period  at  which 
fusion  occurs  between  the  manubrium  and  gladiolus  is  vai-iable. 
They  are  usually  continuous  on  the  surface  after  middle  life  though 
the  center  of  the  articulation  often  remains  soft  even  in  the  aged. 

The  anterior  mediastinum  with  its  contents  lies  directly  behind 
the  sternum. 

The  pectoralis  major  is  attached  to  the  anterior  surface  of  the 
bone.  The  sternomastoid,  sternothyroid  and  sternohyoid  are  at- 
tached to  the  upper  end,  while  the  abdominal  muscles  are  attached 
either  directly  or  through  their  aponeuroses  to  the  lower  end  of  the 
bone.  The  diaphragm  and  triangularis  sterni  find  attachments  to 
the  lower  portions  of  the  posterior  surface. 

The  anterior  mediastinum  with  its  contents  lies  directly  behind  the 
sternum.  The  heart  lies  directly  behind  the  lower  two-thirds  of 
the  sternum  (excepting  the  xyphoid  cartilage).  The  pericardium  is 
separated  from  the  bone  by  the  remains  of  the  thymus  gland  above, 
and  a  small  quantity  of  areolar  tissue  below.  Tlie  junction  of  the 
first  and  second  pieces  of  the  sternum  may  be  felt  as  a  transverse 
ridge  on  the  bone,  passing  between  the  attachments  of  the  second 
costal  cartilages. 

Violent  hyperextension,  or  overflexion  of  the  spine,  particularly 
the  latter,  may  produce  fracture  of  the  sternum.  The  violent  im- 
pact of  the  chin  against  the  upper  portion  of  the  bone  is  said  to 
have  produced  the  condition.  A  blow^  on  the  chest  may,  in  rare 
instances,  produce  fracture.  Gunshot  injuries  of  this  bone  are  not 
uncommonly  seen  even  in  civil  life. 

In  the  aged,  when  ossification  invades  the  costal  cartilages,  and  the 
chest  as  a  whole  is  more  rigid,  f  i-acture  is  more  easily  produced ;  but, 
on  the  other  hand,  the  occupation  and  mode  of  life  of  those  advanced 
in  years  expose  less  to  trauma.  A  number  of  irregular  types  of 
fracture  have  been  reported  in  which  the  condition  was  diagnosed 


FRACTURES   OP   THE   STERNUM  455 

as  compound,  comminuted,  multiple  or  longitudinal.  These  types 
of  fracture,  however,  are  extremely  umisual  in  the  sternutn,  the 
great  majority  being  simple  and  transverse  at,  or  near,  the  junction 
of  the  first  and  second  pieces  of  the  bone.  The  next  most  common 
deformity  is  one  in  which  the  upper  fragment  is  displaced  forward 
and  slightly  overlaps  the  lower  piece.  The  common  deformity  con- 
sists in  a  displacement  of  the  lower  end  of  the  upper  fragment 
behind  the  lower  fragment.  The  deformity  is  so  characteristic  and 
pronounced  that  a  diagnosis  can  usually  be  made  by  inspection  alone. 


Fig.   538. — Fracture  of  the  sternum.      Arrow  indicates  position  of  fracture  which  is 
in  perfect  reduction.     Case  of  Dr.  N.  A.  Thompson. 

Sometimes,  however,  a  simple  transverse  fracture  may  exist  without 
displacement,  when  the  condition  can  only  be  recognized  by  palpa- 
tion, pressure  being  made  first  on  one  fragment  and  then  on  the 
other.  The  next  most  common  site  of  fracture  is  at  or  near  the 
junction  of  the  first  and  second  pieces  of  the  gladiolus  and  resembles 
closely  the  more  usual  fracture  occurring  at  Ludwig's  angle. 

Symptoms. — The  close  relation  existing  between  the  sternum  and 
thoracic  viscera  frequently  results  in  complications  involving  these 
structures.  It  is  seldom  that  we  find  fracture  of  the  sternum  un- 
accompanied by  other  injuries,  so  that  the  symptom-complex  fre- 


456  FRACTURES   AND    DISLOCATIONS 

(|U('iitly  includes  coiidilioiis  siicli  as  t'l'ai'turc  of  the  I'ihs,  t'l'acturc  of 
the  spine,,  poiu't  rat  ill  ii"  wounds  of  the  chest,  clc  lu  fracture  of  tlie 
sternuin  the  patient  usually  assniiies  a  hollow  -chested  attitude  which 
is  cliai-acteristic  both  in  the  erect  and  reeumlient  positions.  liespira- 
tion  is  usually  painful,  rapid  and  su|)eilii-ial,  reseinhlinii'  that  seen 
in  fracture  of  the  ribs. 

Inspection  and  ])alpatioii  of  llie  chest  usually  reveals  the  charac- 
teristic deformity  in  the  upper  part  of  the  sternuin.  AVlien  no 
deformity  exists,  crepitus  is,  as  a  i-ule,  elicited  without  difficulty 
and  in  some  instances  may,  by  means  of  the  stethoscope,  be  recog- 
nized with  every  respiration. 

Dislocations  between  the  first  and  second  portions  of  the  sternum, 
in  young  persons,  produce  practically  the  same  symptoms  except 
that  crepitus  is  more  likely  to  be  cartilaginous.  The  distinction 
between  the  two,  however,  is  clinically  of  little  importance. 
Cyanosis  and  dyspnoea  may  occur  as  the  result  of  direct  pressure 
from  the  displaced  fragment. 

Treatment. — AVhen  deformity  is  absent  from  the  first,  or  if  reduc- 
tion has  taken  place  spontaneously  as  sometimes  occurs  in  normal 
respiration  or  in  coughing,  the  only  indication  in  the  treatment  is 
immobilization,  which  is  most  satisfactorily  accomplished  by  strap- 
ping the  chest  with  adhesive  plaster  in  a  manner  similar  to  that 
employed  in  fracture  of  the  ribs.  'Direct  pressure  on  either  of  the 
fragments  may  be  obtained  by  a  pad  of  gauze  properly  placed  and 
held  in  position  by  adhesive  plaster  placed  diagonally  across  the 
chest.  A  plaster  cast  ilicluding  the  chest  and  shoulders  may  be 
employed  instead  of  the  adhesive,  although  it  does  not  accomplish 
the  purposes  of  fixation  any  more  satisfactorily. 

When  deformity  is  present,  it  should  be  corrected  before  the  chest 
is  fixed.  The  reduction  of  displacement  is  accomplished  in  all 
instances  by  upward  traction  on  the  upper  fragment,  and  downward 
traction  on  the  lower.  As  a  rule  this  is  effected  by  posture,  the 
traction  and  countertraction  being  applied  indirectly  through  the 
muscles  and  other  portions  of  the  thorax. 

If  the  patient  is  placed  on  a  table  in  the  dorsal  position  with  head 
and  shoulders  over  the  edge  so  that  hyperextension  of  the  spine  is 
accomplished,  reduction  will  usually  follow  without  further  manipu- 
lation of  the  fragments.  Raising  the  arms  above  the  head  and  direct 
pressure  on  the  projecting  fragment  will  facilitate  correcting  the 
deformity  when  simple  liyi)erextension  of  the  spine  proves  insuf- 


PRACTrTRES    OP    TITE    STERN  (J  M 


457 


ficient.     After  the  fragment  has  ))een  brouglit  into  j)r'oi)er  position 
the  chest  is  fixed  as  previously  described. 

Operative  Treatment. — Various  methods  have  been  described  for 
the  open  treatment  of  these  deformities  when  simpler  methods  have 
failed  to  accomplish  reduction,  but  it  will  be  unnecessary  to  enter 
into  the  minutiaB  of  these  sutgical  procedures  since  they  all  are  based 


Pig'.    539. — Melhol    of    conectin;    tiefoimitv    in    overridin-;;    fracture    of    sternum. 


Pig.   540. — The  method  shown  in  Pig.   539  has  been  supplemented  by   direct   upward 
pressure  on  the  inner  ends  of  the  clavicles  with  the  finger  tips. 

on  the  same  principles  of  traction,  counter  traction  and  manipula- 
tion after  the  fragments  have  been  exposed  by  incision.  Elevation 
has  been  accomplished  by  means  of  screws  inserted  into  the  depressed 
fragment.  As  a  rule  it  will  not  be  a  difficult  matter  to  pry  the 
depressed  portion  of  the  sternum  back  into  position  with  some  strong 
instrument  such  as  a  periosteal  elevator.     The  greatest  care  should 


458  FRACTURES   AND   DISLOCATIONS 

be  exercised  uot  to  insert  tlie  instrument  too  far  or  in  any  way, 
either  by  cutting  or  laceration  of  tlie  tissues,  to  open  the  pleural 
or  pericardial  sacs.  In  oi)eratiny  in  this  region  wo  should  bear  in 
mind  the  course  of  the  internal  inaiiuuary  artery  one-half  inch 
external  to,  and  parallel  with  the  lateral  border  of  the  sternum.  If 
the  origin  of  the  pectoralis  major  interferes  with  the  operative 
manipulations  the  fibres  should  be  cut  away  so  that  the  fragments 
are  properly  exposed.  AVhen  reduction  has  been  accomplished  the 
incision  is  to  be  closed  without  drainage,  and  provision  made  in  the 
fixation  apparatus  for  the  subsequent  dressing  of  the  wound  during 
the  after-treatment. 

After-Treatment. — Fixation  of  the  chest  should  be  maintained 
for  from  six  to  eight  weeks  following  the  accident  and  heavy  work 
or  violent  exercise  forbidden  for  another  two  or  three  weeks.  Ditfer- 
ent  types  of  steel  braces  and  apparatus  have  been  used  with  success 
to  immobilize  the  chest  and  neck  though  they  are  seldom  called  for  in 
a  simple  case. 

Prognosis. — The  prognosis  of  simple,  uncomplicated  fracture  of 
the  sternum  is  good  both  as  to  life  and  function,  but  the  frequency 
with  Avhich  this  fracture  is  associated  with  severe  crushing  injuries, 
such  as  fractures  of  the  spine  and  complications  of  the  thoracic 
viscera,  renders  the  outlook  variable,  since  the  prognosis  in  these 
i2:stances  is  that  of  the  complication  rather  than  the  fracture  itself. 


CHAPTER  XXXIII. 

FRACTURES  OF  THE  RIBS. 

Surgical  Anatomy. — The  surprising  degree  of  trauma  whieli  the 
ribs  are  capable  of  withstanding  is  the  result  of  their  mobility  and 
the  natural  spring  which  they  possess.  The  first  rib  is  the  shortest, 
the  seventh  the  longest.  They  are  diagonally  placed  so  that  the 
posterior  end  of  a  given  rib  is  at  a  considerably  higher  level  than 
the  anterior  extremity.  They  increase  in  obliquity  from  above 
downAvard  to  the  ninth  rib,  below  which  they  become  again  more 
horizontal.  The  upper  seven  ribs  are  connected  with  the  sternum 
through  their  own  costal  cartilages.  The  next  three  are  attached 
through  their  cartilages  to  the  ribs  above,  while  the  remaining  two 
are  floating.  The  first  rib  joins  the  sternum  through  its  cartilage 
just  below  and  behind  the  sterno-clavicular  articulation.  The  sec- 
ond costal  cartilage  joins  the  sides  of  the  sternum  at  Ludwig's 
angle.  The  lower  border  of  the  pectoralis  major  leads  to  the  fifth 
rib,  while  the  first  visible  digitation  of  the  serratus  magnus  is 
attached  to  the  sixth.  .  The  lower  border  of  the  tenth  rib  forms, 
from  a  surgical  standpoint,  the  lower  border  of  the  thorax.  The 
inferior  margin  of  each  rib  is  grooved  on  its  deep  aspect  for  the 
corresponding  intercostal  vessels.  The  sixth  and  seventh  ribs  are 
the  ones  most  frequently  fractured.  The  upper  two  ribs  are  more 
or  less  protected  by  the  clavicle,  while  the  heavy  muscles  of  the  back 
and  the  unattached  condition  of  the  eleventh  and  twelfth  renders 
these  lower  ribs  even  more  capable  of  withstanding  trauma. 

The  ribs  may  be  broken  by  direct  or  indirect  violence.  The 
former  occurs  when  the  rib  is  fractured  and  driven,  inward  at  the 
point  of  impact ;  the  latter  when  breaking  results  from  bending,  as 
in  forcible  compression  of  the  chest  wall.  The  weakest  point  in 
the  rib  is  just  anterior  to  the  angle,  and  it  is  here  that  fracture 
most  often  occurs  when  the  result  of  indirect  violence.  The  costal 
cartilages  may  be  broken,  a  not  uncommon  site  being  at  their  junc- 
tion with  the  ribs.  The  close  relations  existing  between  the  ribs 
and  pleura  account  for  the  frequency  of  complications  involving 

459 


460 


FRACTURES   AND   DISLOCATIONS 


this   inembi'aiu'   and   tlic   uiidtTlyinii-   lun^.   especially    in    fractures 
produced  liy  indirect  \iolence. 

When  a  sinj>le  rib  is  fractured  there  is  little  tendency  toward 
displacement,  since  both  ends  are  fixed,  and  tlie  intercostal  mus- 
cles maintain  its  i-elations  with  the  ribs  above  and  below.  When 
a  number  of  ccnsecntive  ribs  are  fractured  thei-e  is  frroat(>r  proba- 


f   third,   fourth,    fifth   nnd   sixth    ribs. 


bility  of  deformity,  as  is  also  the  case  when  a  single  rib  is  broken 
in  two  or  more  places. 

Dislocation  of  the  ribs  may  occur  at  either  end,  though  their 
structure  and  the  strength  of  their  articulations  render  fracture 
by  far  the  more  common  injury.  Dislocation  may  occur  at  the 
vertebral  ends  of  the  ribs  or  at  the  mesial  end  of  the  first,  second, 
eighth,  ninth  and  tenth  costal  cartilages. 


FRACTIIUIOS    OF    TJIK    RIBS  461 


Symptoms. — Pain  is  a,  coiistant  ,syiii])1()iii,  hcinn'  well  localizod  in 
the  region  of  the  fracture.  It  is  greatly  increased  by  breathing, 
especially  by  deep  inspiration.  Coughing  and  sneezing  render  the 
suffering  momentarily  more  intense.  The  patient  usually  stands 
or  sits  in  an  attitude  cliaracteristic  of  the  condition,  willi  the  trunk 


Pig.  542. — Caving  in  of  chest  with  fracture  of  a  number  of  ribs,  the  result  of  direct 
violence.  Note  the  flattened  condition  of  the  chest  on  the  patient's  right  side.  Case 
seen   with   Dr.   H.    R.    McGraw. 


Fig.    543. — Fracture    and    displacement    of    a    costal    cartilage. 

bent  slightly  forward  and  toward  the  injured  side.  Respiration 
is  shallow  and  rapid.  The  pectoral  excursion  on  the  injured  side 
is  usually  less  than  that  observed  on  the  well  side  of  the  chest. 
Abnormal  mobility  is  often  present  in  the  fractured  rib  near  the 
site  of  the  break.     Crepitus  may,  or  may  not,  be  present  accord- 


462  FKAC'TCHKS    AND    DISLOCATION'S 

ing  to  tlio  roliitiou  of  tlu'  serrated  ends  of  tlie  fragments.  Swell- 
ing of  the  parts  is  slight,  if  present  at  all.  Ecchymosis  may  make 
its  appearance- within  the  first  twenty-four  to  forty-eight  hours 
following  the  accident.  The  lung  may  be  penetrated  by  one  of 
the  fractured  ends.  Bloody  expectoration  and  subcutaneous 
emphysema  are  the  most  common  indications  of  this  complication. 
In  pronounced  cases  the  subcutaneous  tissues  of  the  chest,  face, 
neck  and  arms  may  be  extensively  distended  with  air.  Palpation 
gives  a  distinct  sense  of  crepitation  when  air  exists  Mdthin  the  tis- 
sues.    Traumatic  pneumonia  may  follow  if  the  lung  is  injured. 

Diagnosis. — The  diagnosis  is  based  on  the  symptoms  just  de- 
scribed, together  with  a  careful  and  systematic  examination  of  the 
chest.  The  ribs  should  be  palpated  in  order,  from  above  down- 
ward, for  the  purpose  of  recognizing  crepitus  and  abnormal  mo- 
bility. If  pressure  is  made  on  a  given  rib,  anteriorly  (say  the 
seventh),  while  the  fingers  of  the  opposite  hand  rest  on  the  same 
rib  in  the  posterior  axillary  line,  the  motion  imparted  to  the  rib, 
anteriorly,  may  be  recognized  by  the  opposite  hand  if  the  rib  is 
intact  between  the  points  of  palpation.  If  fracture  is  present, 
crepitus  may  be  elicited  in  this  manner,  and  dissolution  of  con- 
tinuity appreciated  when  present.  As  previously  stated  the  ribs 
possess  a  certain  amount  of  spring,  which  quality  should  be  tested 
when  examining  for  fracture.  If  the  chest  be  gently  compressed 
antero-posteriorl.y  pain  will  be  produced  or  increased  at  the  seat  of 
fracture,  which  is  promptly  recognized  and  indicated  by  the  pa- 
tient. Crepitus,  even  with  shallow  respiration,  may  sometimes  be 
determined  by  the  stethoscope.  Fractures  of  the  posterior  ex- 
tremities of  the  ribs  are  not  infrequently  extremely  difficult  to  diag- 
nose because  of  their  deep  situation  under  the  heavy  muscles  of 
the  back.  In  such  instances  a  radiogram  will  make  the  diagnosis 
possible. 

Treatment. — Fixation  of  the  injured  side  of  the  chest  is  the  first 
indication  in  fractures  of  the  ribs.  This  is  best  accomplished  by 
strapping  the  chest  with  zinc  oxide  adhesive  plaster.  The  usual 
method  of  applying  the  adhesive  straps  or  swathe  to  the  back  first, 
and  then  encircling  the  chest  during  expiration  is  contrary  to  the 
principles  of  surgical  anatomy  in  this  region.  The  anterior  por- 
tion of  the  chest  is  the  movable  part,  while  the  spinal  portion  is 
fixed.  The  strapping  therefore  should  be  done  from  before  back- 
ward   (see  Fig.   54-4).     When  the  injured  side  of  the  thorax  is 


1<^RACTIJRES    OF    THE    RIBS  463 

fixed,  relief  from  suffering  is  prompt  and  pronoiincfid.  The  fact 
that  the  chest  in  respiration  moves  as  a  whole,  renders  it  unneces- 
sary to  always  apply  the  strapping  directly  over  the  rib  fractured. 
If  the  lower  portion  of  the  chest  is  fixed  on  the  affected  side,  relief 
will  follow,  even  though  the  fracture  be  situated  in  one  of  the 
upper  ribs.  In  other  words,  if  the  lower  four  or  five  ribs  are  fixed 
on  the  affected  side  motion  in  the  entire  half  of  the  chest  will  be 
restricted.  In  severe  fractures  of  the  ribs,  or  in  those  presenting 
symptoms  of  pulmonary  complications  the  strapping  should  not 
be  applied  too  tightly,  lest  additional  injury  be  done  to  the  lung 
by  forcing  a  displaced  fragment  or  spicule  into  its  substance.  If 
suft'ering  is  not  sufficiently  relieved  by  strapping,  the  use  of  opiates 


Fig.   544. — Adhesive   plaster    strapping   for    fracture    of    the    ribs. 

may  be  necessary  during  the  first  day  or  two  following  the  accident. 

In  fleshy  persons,  especially  in  women  with  pendulous  breasts, 
fixation  of  the  thorax  is  more  difficult.  The  amount  of  subcu- 
taneous tissue  renders  the  skin  more  mobile  and  cutaneous  irrita- 
tion seems  to  be  more  readily  produced,  accordingly  strapping  is 
less  satisfactory.  In  these  cases  a  swathe  snugly  surrounding  the 
lower  chest  will  usually  answer  the  purpose  better  than  strapping. 

Subcutaneous  emphysema  does  not  ordinarily  call  for  special 
measures,  yet  should  the  condition  become  severe  it  may  be  re- 
lieved by  multiple  incisions. 

After-Treatment. — The  fixation  dressing  should  be  maintained 
for  a  period  of  about  three  weeks.  In  the  milder  cases  in  which 
a  single  rib  is  fractured,  the  patient  may  be  up  and  about  immedi- 


464  FRACTURES    AND    DISLOCATTONS 

ati'ly  follow  iii^i-  the  iiijurv.  When  the  coiidition  is  more  severe, 
as  when  a  immbtT  of  ribs  are  fi-aeturecl,  or  tlie  lung  penetrated, 
treatment  in  reeumheney  is  demanded.  If  respiration  is  painful 
or  dit'lii-iilt  ill  the  dorsal  position  the  patient  may  lind  eomfort  in 
tnrninu'  on  his  side,  or  tlie  l)aekrest  may  he  used  to  raise  him  to  a 
semi-sittinu'  posture.  It  will  often  be  neeessary  to  tighten  or  re- 
apiil\  the  strapping  if  it  licroines  loosened,  oi"  if  cutaneous  irri- 
tation dexi'lojis.  For  these  reasons  tlie  i)atient  should  be  kept 
under  close  obsiu'vation  especially  during  the  early  ]nirt  of  the 
aftei'-trcatiiu'iit.  A  linen  swathe  iiuiy  l)e  used  about  the  chest  if, 
for  any  i-eason,  sti'api)ing  seems  inadvisable. 

Prognosis. — Fi-actures  of  single  ril)s  are  aliiu)st  invai'iably  fol- 
lowed by  complete  restoration  of  function.  Union  with  deformity 
is  not  likely  to  be  followed  by  ill  effects.  The  i)rognosis  of  severe 
crusliing  injuries.  i)enetrations  of  the  lung,  trauumtic  pneumonia, 
etc.,  is  that  of  the  complication  i-athei'  than  of  the  fracture  itself. 


CHAPTER  XXXIV. 

FRACTURE-DISLOCATIONS  OF  THE  SPINE. 

Considerable  useless  distinction  has  been  made  between  ''frac- 
ture" and  ''dislocation"  of  the  vertebrge.  The  use  of  the  X-ray, 
of  recent  years,  has  demonstrated  the  fact  that  nearly  all  spinal 
fractures  are  complicated  by  at  least  some  articular  displacement, 
and  that  dislocations  rarely  occur  without  fracture  of  some  por- 
tion of  the  vertebrge.  This  close  association  of  the  two  conditions, 
therefore,  renders  the  term  "fracture-dislocation"  the  most  satis- 
factory and  accurate,  and  it  will  be  understood  in  the  subsequent 
discussion  of  injuries  to  the  spine  that  one  condition  rarely  occurs 
without  the  other.  Dislocations,  uncomplicated  by  fracture,  are 
sometimes  seen  in  the  cervical  spine  but  almost  never  in  the  lower 
portions  of  the  column. 

The  importance  of  fractures  and  dislocations  of  the  spinal  column 
lies  not  so  much  in  the  bony  injury  sustained  by  the  vertebras,  as 
in  the  damage  which  may  be  inflicted  on  the  spinal  cord  contained 
Mdthin  the  spinal  canal.  In  other  words,  the  serious  complica- 
tions which  follow  fracture  of  the  spine  are  shown  by  the  symp- 
toms of  injury  to  the  cord  or  spinal  nerves  rather  than  those  of 
fracture  of  the  spinal  column.  The  diagnosis  and  treatment, 
therefore,  come  more  properly  under  the  head  of  neurology  than 
of  surgery.  Since  such  is  the  case  it  will  readily  be  seen  that  it 
is  well  for  the  surgeon,  when  possible,  to  have  the  counsel  and 
cooperation  of  an  experienced  neurologist  in  dealing  with  fracture- 
dislocations  of  the  spine. 

Surgical  Anatomy. — The  character  of  the  hony  structure  of  the 
vertebra  is  of  importance  in  explaining  the  deformity  which  occurs 
in  fracture-dislocations  of  the  spine.  The  vertebral  body  is  com- 
posed of  a  cancellous  structure  similar  to  that  seen  in  the  ends 
of  the  long  bones.  The  surface  is  composed  of  a  layer  of  com- 
pact tissue  on  which  the  strength  of  the  body  largely  depends. 
In  compression  strains,  little  resistance  remains  after  this  bony 
capsule  of  compact  tissue  has  been  fractured;  the  internal  can- 

465 


466 


FRACTURES   AND   DISLOCATIONS 


I't'lloiis  tissue  cruslu's  readily  and  the  Ixidy  collapses.  The  verte- 
bral arelu'H,  though  less  in  bulk,  are  eoini)osed  of  a  heavy  compact 
tissue  with  a  CQinparatively  small  amount  of  enclosed  cancellated 
structure.  The  result  is  that  fracture  of  this  portion  of  the  verte- 
bra is  more  distinct  and  clean-cut  in  nature,  witli  little  or  no  loss 
of  bone  through  crushing  or  impaction  of  cancellous  tissue.  The 
difference  in  the  types  of  fracture  occurring  in  these  two  portions 
of  a  verte])ra  may  be  likened  to  the  difference  existing  between 
fracture  taking  ])laee  in  the  shaft,  as  comjiared  to  that  seen  in  the 


Fig.    545. — Fracture  of   the  bodies   of  the  second,   third   and   fourth   cervical   vertebrae 
with   kyphotic  deformity. 


expanded  upper  extremity  of  a  long  bone,  such  as  the  humerus. 

The  usual  strain  producing  fracture  of  the  spine  is .  that  of 
hyperflexion,  and  the  effect  upon  the  spinal  column  as  a  whole  is 
similar  to  that  occurring  when  other  materials  are  subjected  to 
bending  strain.  The  convex  side  of  the  rod  or  column  is  under 
tension,  the  concave  side  under  compression,  while  the  intermediate 
part  is  in  a  neutral  condition  until  either  the  convex  or  concave 
side  of  the  column  breaks.  With  hypertiexion,  therefore,  the 
bodies  of  the  vertebrae  are  under  compression  while  the  vertebral 


FRACTURE-DISLOCATIONS   OF    SPINE 


467 


arches  and  connecting  ligaments  are  subjected  to  tension.  In  most 
instances  the  compression  strength  of  the  bodies  is  less  than  the 
tension  strength  of  the  posterior  spinal  ligaments.  The  usual  re- 
sult therefore,  when  the  strain  becomes  greater  than  the  spine  can 
withstand,  consists  of  a  crushing  of  one  or  more  of  the  vertebral 
bodies  with  kyphosis  as  a  consequent  deformity. 

The  planes  of  the  articular  surfaces  in  the  cervical  spine  are 
more  nearly  parallel  with  the  upper  and  lower  surfaces  of  the 
bodies  than  in  other  portions  of  the  spine.     This  less  firm  inter- 


Fig.  546. — Fracture  of  body  of  second  cervical  vertebra  witli  subluxation  between 
bodies  of  second  and  third  vertebras.  Fracture  of  second  and  third  vertebras  near 
pedicles. 

locking  in  the  cervical  region  accounts  to  some  extent  for  the  com- 
parative frequency  of  uncomplicated  dislocations  of  the  vertebrae 
in  the  neck.  The  upper  portions  of  the  spine  normally  carry  less 
weight  than  the  lower;  hence  the  lighter  structure  in  the  cervical 
region.  Accordingly  the  same  degree  of  trauma  wall  more  surely 
produce  fracture  or  dislocation  in  the  neck  than  in  other  regions 
of  the  spine.  As  already  explained  the  usual  deformity  is  ky- 
photic; yet  we  may  see  angular  displacements  in  other  directions, 
and  the  deformity  may  be  overriding  or  rotary,  as  well  as  angular. 


468 


FRACTURES    AND    niSL(  )('ATl()i\S 


In  Pott's  disease  tlie  vertebral  body  gives  way  uiulcr  iiorinal  strain 
as  a  result  of  diseased  bony  tissue;  in  fraeture  of  the  spine,  with 
kyphosis,  tlie  normal  body  eoHajJses  because  of  excessive  strain ; 
the  deformity  is  similar  in  both  instances. 

In  the  dorsal  region,  the  articular  surfaces  change  so  they  are 
more  nearly  at  right  angles  with  the  jirticuhir  planes  between  the 
bodies.  This  results  in  greater  strength  and  lessened  mobility,  so 
that  it  is  almost  impossible  to  slide  one  vertebra  on  another  (be- 
yond   ligamentous    limits)     without    producing    fracture.     In    the 


Fig.    547. — Dislucatimi    Ijflwuen    tin 
displacement   of  the  skull. 


lii'st    iind    setuiul    cervical    verlebrie    with    forward 


lumbar  region  the  articular  surfaces  are  also  nearl\'  at  right  angles 
with  the  articulations  between  the  bodies  although  they  correspond 
more  closely  witli  tiie  sagittal  than  with  the  coronal  plane. 

The  tips  of  the  vertebral  spines  are  subcutaneous  and  palpable 
from  the  sixth  or  seventh  cervical  to  about  the  fourth  sacral.  The 
anterior  surfaces  of  the  bodies  of  the  upper  four  cervical  may  be 
palpated  through  the  pharynx;  the  lumbar  bodies  through  the 
anterior  abdominal  wall,  in  thin  persons;  and  the  coec^yx  and 
lower  end  of  the  sacrum  through  the  rectum.     Otherwise  the  heavy 


PRACTURE-DISI.OCATIONK   OP    SPINE 


469 


Fig.    548. — Fracture  of  the  lower  dorsal   and   upper  lumbar  vertebrte  with  lateral  de- 
formity 


470 


FRACTURES   AND   DISLOCATIONS 


fascia?  and  erector  spina?  mass  so  conceal  the  deep  portions  of  the 
vertebrte  that  it  is  impossible  to  accurately  determine  their  con- 
dition and  positions  by  palpation. 

The  spinal  cord  lies  within  the  spinal  canal,  extending  down- 
ward from  the  foramen  magnum  to  about  the  level  of  the  inter- 
vertebral disc  between  the  first  and  second  lumbar  vertebrge.  The 
level  of  the  lower  end  of  the  cord  varies  somewhat  in  different  per- 
sons.    It  is  said  to  extend  to  a  relatively  lower  level  in  women  than 


Fig.   549. 


Fig.   550. 


Fig.   551. 


Figs.  549,  550  and  551. — Posterior  view,  sagittal  section  and  anterior  view  of  an 
old  fracture  of  the  spine.  Note  the  constriction  of  the  spinal  canal  and  crushing  of 
the  Cauda  equina   opposite  the   third  lumbar  verteVjra. 

in  men,  in  short  persons  than  in  tall.  This  is  explained  by  the 
growth  of  the  individual.  Early  in  fcetal  life  the  cord  occupies 
the  entire  spinal  canal  but  the  subsequent  disproportion  in  growth 
between  the  spinal  column  and  cord  finds  tlie  conus  terminal  is  on 
a  level  with  the  third  lumbar  vertebra  at  birth  and  later  in  life 
the  cord  terminates  at  the  first  or  second  lumbar  according  to  the 
extent  of  longitudinal  growth  in  the  spinal  column. 

In  the  early  foetal  arrangement  the  spinal  nerves  arise  from  the 


FRACTURE-DISLOCATIONS   OK    SI'INE 


471 


death. 


Fig.    553. — X-ray  plate  of  case  shown  in  Figs.   549,   550  and  551,   some  weeks  before 


472  FRACTURES   AXD    DISLOCATIONS 

cord  opposite  the  iiil('rviTtt'l)i'al  lor;iiiiina  tlii'oiigli  which  tlu\y 
emerge.  The  fat-t.  liowevcr,  thai  Ihe  spine  grows  fastci-  than  the 
cord  lowers  the  level  of  the  si)inal  exit  for  a  given  nerve,  with 
relation  to  its  spinal  eord  origin.  All  of  the  spinal  nerves,  there- 
fore, with  the  exception  of  the  tirst  two  cervical,  ha\t'  a  downward 


Fig.    5.5y. — Friicture   of   tlie   liody   of   the   fifth   lumbar   vertfljra    at    the   point    indicated 
by  arrow. 

intraspinal  course  of  greater  or  less  extent,  varying  with  the  level 
of  the  nerve.  The  lower  the  nerve,  the  longer  its  intraspinal 
course. 

The  spinal  dura  or  "theca"  forms  a  well,  within  the  spinal  canal 
extending  from  the  foramen  magnum  to  ahout  the  third  sacral 
vertebra.     The  cord  is  susi)ended  within  this  well  and  surrounded 


FRAOTrTRE-DTST/JCATIONR   OF    SPINE  473 

by  cerebrospinal  fluid  in  sneh  a  manner  that  injury  hy  direct  vio- 
lence is  almost  impossible  if  the  spinal  column  remains  intact. 
The  denticulate  ligament  and  spinal  nerves  steady  the  cord  within 
the  theca  and  serve  to  prevent  its  coming  in  contact  with  the  walls 
of  the  canal. 

The  tracts  within  the  cord  are  composed  of  jnedullated  aneurilem- 
matic  axones,  and  when  these  fibres  degenerate,  following  injury 
or  disease,  regeneration  does  not  take  place.  Loss  of  function, 
therefore,  is  permanent.  The  spinal  nerves,  however,  are  both 
medullated  and  neurilemmatic  and  will  regenerate  under  favorable 
conditions.  This  difference  in  structure  and  power  of  regeneration 
explains  the  invariable  necessity  for  operative  intervention  to  re- 
move pressure  in  injuries  of  the  cauda  equina. 

Symptoms. — The  symptoms  of  fracture  of  the  spine  are,  firstly, 
those  of  the  bony  lesion  (the  fracture  itself)  and  secondly,  those 
resulting  from  injury  to  the  spinal  cord  or  nerves. 

The  symptoms  of  fracture  of  the  spinal  column  are : 

1.  Local  pain  and  spasm. 

2.  Abnormal  mobility. 

3.  Crepitus. 

4.  Deformity. 

5.  Loss  of  function. 

The  symptoms  following  injury  to  the  cord  and  spinal  nerves  are : 

6.  Shock   (and  unconsciousness  in  cervical  fracture). 

7.  Changes  in  pulse,  temperature  and  respiration. 

8.  Motor  disturbances. 

9.  Sensory  disturbances. 

10.  Disturbances  in  reflexes. 

11,  Trophic  changes. 

Symptoms  of  Fracture  of  the  Spinal  Column. — 

1.  Pain  is  usually  present  at  the  seat  of  fracture,  and  is  similar 
in  character  to  pain  produced  by  fracture  elsewhere.^  It  is  in- 
creased by  motion  and  severe  enough  in  some  instances  to  produce 
syncope. 

2.  Abnormal  mohility  is  usually  present  and  can  be  recognized 
if  the  fracture  has  been  at  all  severe.     It  is  generally  possible  to 


1  Reflex  pain  is  not  here  considered. 


474 


FRACTURES   AND   DISLOCATIONS 


riox  the  spine  beyond  normal  limits,  but  the  (laii^cr  of  pi'Otlueinp: 
OT  increasing'  injury  to  the  spinal  cord  should  pi't'cludc  any  and  all 
unnecessary  manii>ulations. 

3.  Crepitus  may  or  nuiy  not  be  pceseid  but  any  attempt  to  elicit 
same,  sim])ly  for  diagnostic  purposes,  is  abs()lu1el\-  to  be  coiulennied 
on  account  of  tlie  i)ossibility  of  injury  to  the  spinal  cord  or  nerves. 

4.  Dc  for  mil  II  varies  with  the  region  of  the  spine  injured  and  the 
nature  and  degree  of  the  fracture.  It  is  almost  invariably  present. 
If  the  back  be  thoroughly  inspected  and  carefully  pal])ated  the 
surgeon  will,  as  a  rule,  experience  little  dif^cult}^  in  recognizing 


I'ig.   655. 


Figs.  554  and  555. — Fracture  of  the  spines  of  the  third,  fourth  and  fifth  cervical 
vertebrae  and  of  the  bodies  of  the  fifth  and  sixth.  The  thumb  is  depressed  into  the 
hollow  caused  by  the  displacement  of  the  fractured   spines. 

the  gravit}^  of  the  condition  even  though  the  details  of  the  fracture 
cannot  he  ascertained  without  resorting  to  the  use  of  the  X-ray. 
The  usual  deformity  consists  of  anterior  angular  displacement  of 
that  portion  of  the  spine  above  the  fracture,  with  resultant  kyphosis. 
In  unusual  instances  the  loss  of  vertebral  alignment  may  be  rotary. 
In  severe  cases  overriding  as  well  as  angular  deformity  of  the 
spinal  column  may  occur.  Kyphosis  is  often  sufficiently  pro- 
nounced to  be  recognized  by  inspection  alone.  It  is  seldom  that 
the  important  elements  cannot  be  determined  by  palpation.  Frac- 
ture of  one  or  more  of  the  spinous  processes  with  loss  of  alignment 
in  the  tips  of  the  spines  may  produce  a  slight  deformity  which  can 


FRACTURE-DISLOCATIONS   OF   SPINE 


475 


Fig.    556. 


Fig.   557. 

Figs.  556  and  557. — Fracture  of  the  spine  in  tlie  lower  dorsal  region  a  few  min- 
utes following  the  accident.  Arrow  in  upper  photograph  indicates  the  visible  irregu- 
larity in  the  spinous  processes.  In  the  lower  plate  (Fig.  557)  the  finger  is  pressed 
into  the  depression. 


476  FRACTURES    AND    DISLOCATIONS 

be  recognized  Ity  i)al])alion,  if  not  by  inspection  alone.  In  isolated 
fracture  of  the  spinous  processes  tlie  deform  ity  is  slij^ht  and  not 
aeeompanit'd  by  symptoms  of  fracture  of  the  column  itself,  such 
as  ang-nlation  of  the  spine,  shock,  motor  and  sensory  disturbances, 
loss  of  function,  etc.  Fi'acture  of  the  arches  may  be  accompanied 
by  symptoms  of  cord  injury  if  the  fi-agments  have  been  displaced 
foi'ward  into  the  si)inal  canal. 

5.  Loss  of  function  is  inevitable  in  fracture  of  the  s|)iiial  column, 
and  will  be  more  or  less  complete  according-  to  the  severity  of  the 
injui-y.  Shock,  pain,  and  cord  injury  may  disable  the  patient, 
but  aside  from  these  conditions  the  mechanical  disturbances  pro- 
duced by  the  fracture  are  sufficient  to  prevent  the  patient  from 
standing  or  sitting.  Spasm  of  the  nuiscles  of  the  trunk,  especially 
the  erector  spina?  mass,  will  be  present,  and  represents  Nature's 
attempt  at  splinting  the  injured  parts.  Loss  of  function  through 
isolated  fracture  of  the  spinous  processes,  is  mainly  the  result  of 
local  pain,  especially  when  the  muscles  attached  to  the  involved 
spine  are  brought  into  action.  Local  swelling  and  ecchymosis  are 
seldom  pronounced,  if  they  occur  at  all.  The  extravasated  blood 
and  fluids  of  inflammation  are  so  bound  down  by  the  heavy  dorsal 
fascia  covering  the  erector  spime  mass,  that  they  seldom  reach  the 
surface. 

Symptoms  Followino  Injury  to  the  Cord  and  Spinal 
Nerves. — The  symptoms  following  injury  to  the  spinal  cord  or  the 
nerves  contained  within  the  spinal  canal  vary  with  the  complete- 
ness and  region  of  the  injury.  The  nature  and  degree  of  these 
sj'mptoms  are  explained  by  reverting  to  the  anatomy  of  the  spinal 
cord  and  the  distribution  of  the  spinal  nerves.  Slight  pressure 
on  the  spinal  cord,  such  as  produced  by  hemorrhage  (and  in  some 
instances  slight  bony  displacement),  is  prone  to  produce  irritation 
of  the  spinal  centers  which,  if  allowed  to  continue,  is  not  uncom- 
monly followed  by  a  degeneration  of  the  affected  cells  and  their 
axones.  Destniction  of  spinal  cord  tissue  is  invariably  accom- 
panied by  prompt  loss  of  function  in  the  destroyed  cells,  and 
interruption  of  impulses  in  the  damaged  white  tissue  of  the  cord. 
If  the  damage  to  these  cells  has  been  at  all  severe,  degeneration 
ensues  regardless  of  relief  of  pressure.  If,  however,  pressure  is 
not  removed  pressure  myelitis  is  almost  sure  to  follow,  the  degen- 
erative process  will  be  more  extensive,  and  adjoining  cells  and 
tracts  will  be  involved,  which   were  primarily   unaffected  at  the 


FRACTURE-DTRIiOOATTONS   OF    SI'INK 


477 


Fig.  558. — Fracture  of  the  lower  doisal  spme  home  eight  years  following  the  in- 
jury. The  cord  was  partially  crushed  and  paralysis  of  the  lower  extremities  with  loss 
of  bladder  and  bowel  contiol  followed.  Note  thechionic  sore  in  the  sacral  region  and 
the  cord  about  the  hips  supporting  a  urinal. 


Fig.  559. — A  case  of  Charcot's  spine  showing  the  same  type  of  kyphotic  deformity 
&s  is  sometimes  seen  in  fractures  of  the  lumbar  spine.  Paralysis  of  the  lower  extrem- 
ities and  loss  of  sphiricteric  control  due  to  pressure  on  the  spinal  nerves  within  the 
canal. 


478  FRACTURES   AND    DISLOCATIONS 

time  of  injury.  Tlicrc  arc  none  oL*  the  so-ealled  silent  areas  within 
the  cord  simihir  to  those  existing  in  the  brain,  and  hence  lesions 
of  tlie  coi"d.  either  partial  or  complete,  ai'c  always  attcnchnl  by  dis- 
turhances  in  function. 

6.  SJiock,  at  least  in  a  mihl  degree,  accompanies  all  uncomi)li- 
cated  fractures  of  the  spine  and  is  greatly  augmented  when  the 
cord  is  injured.  Unconsciousness,  however,  i-arely  occurs  unless 
the  injury  is  in  the  region  of  the  upper  four  cervical  vertebrge. 

7.  Except  in  injuries  of  the  upper  cervical  region  pronounced 
changes  in  temperature,  respiration  and  pulse  do  not  occur  im- 
mediately following  the  accident.  Shock  may  influence  the  tem- 
perature, pulse  and  respiration,  but  shock  may  occur  in  many  con- 
ditions and  is  not  characteristic  of  cord  lesions.  Later  in  the 
coiirse  of  the  case  pressure  myelitis,  meningeal  complications  or 
degenerative  processes  within  the  cord  may  cause  a  rise  of  tem- 
perature, with  alterations  in  the  pulse  and  respiration. 

8.  Motor  (lifiiurhances  at  and  below  the  seat  of  fracture,  are  the 
rule  when  the  cord  is  injured  and  the  character  of  these  symptoms 
varies  according  to  the  nature,  region  and  completeness  of  the 
lesion.  In  complete  crushing  of  the  cord  paralysis  will  be  found 
in  the  parts  supplied  by  the  damaged  segments,  and  all  the  seg- 
ments below  them  will  be  thrown  out  of  function.  In  partial  in- 
jury to  the  cord  the  musculature  supplied  by  the  injured  segments 
will  show  more  or  less  complete  flaccid  paralysis,  while  the  muscles 
supplied  by  lower  segments  will  be  spastic.  The  condition  of  the 
muscles  will  often  be  difficult  to  recognize  immediately  following 
the  accident  because  of  the  accompanying  shock  and  temporary 
loss  of  reflexes. 

The  distribution  of  the  thoracic  nerves  is  simple  and  regular, 
and  hence  it  is  an  easy  matter  to  recognize  the  level  of  the  spinal 
injury  when  the  thoracic  segments  are  involved.  When,  however, 
the  injury  is  sustained  by  the  cervical,  lumbar  or  sacral  segments 
it  is  necessary  to  understand  the  different  plexus  formations  to 
appreciate  the  nerve  distributions,  and  to  be  able  to  determine 
from  the  motor  and  sensory  symptoms  which  spinal  segments  have 
been  involved.  In  partial  lesions  of  the  cord  the  paralyses  are 
often  incomplete  and  asymmetrical.  There  may  be  weakness  in 
certain  muscles,  Avith  spasm,  or  complete  loss  of  function  in  others. 
Irritative  lesions  commonly  become  paralytic  as  the  case  progresses. 
Paralysis  of  unstriped  muscular  tissue  is  seldom  complete  because 


FRACTURE-DISLOCATIONS   OF    SPINE  479 

of  the  additional  nerve  supply  which  it  receives  from  llic  sympa- 
thetic system.  Disturbances  in  the  control  of  the  hhuidcr  and 
bowel  will  be  considered  under  injuries  of  the  lumbar  enlargement. 
The  motor  areas  of  the  cord  are  more  easily  injured  than  the 
sensory,  and  hence  in  partial  lesions  motor  paralysis  is  often  more 
extensive  and  complete  than  are  the  sensory  disturbances.  The 
symptoms  of  cord  injury  following  bony  displacement  are  almost 
always  paralytic  from  the  first  and  are  not  progressive  in  nature. 
But  on  the  other  hand,  hemorrhage  within  or  about  the  cord  is 
often  accompanied  by  irritative  symptoms,  such  as  spasm  or 
tremor,  and  the  intensity  of  these  symptoms  usually  increases  both 
in  degree  and  extent.  Hematomyelia  (hemorrhage  into  the  .sub- 
stance of  the  cord)  and  hematorrhachis  (hemorrhage  about  the  cord) 
are  not  uncommon  complications  of  spinal  cord  injury.  It  is  a 
peculiar  fact  that  crushing  injuries  of  the  cord  are  frequently  fol- 
lowed by  hemorrhage  into  its  substance  a  few  segments  above  the 
site  of  the  lesion.  When  this  secondary  traumatic  hematomyelia 
above  the  lesion  occurs,  it  usually  develops  within  the  first  few  days. 
Hematorrhachis  is  more  properly  a  complication  than  a  sequel, 
since  its  onset  is  prompt  following  injury  to  the  spinal  plexus  of 
veins  at  the  seat  of  injury.  In  either  of  these  conditions  the  sj^mp- 
toms  are,  as  a  rule,  progressive.  The  motor  and  sensory  losses  are 
not  infrequently  preceded  by  evidences  of  irritation  in  the  spinal 
centers.  In  rare  instances  slight  pressure  upon  the  cord  from 
bony  displacement  may  produce  symptoms  simulating  hemorrhage, 
provided  the  pressure  is  not  sufficiently  pronounced  to  produce 
immediate  destruction  of  cord  tissue.  Under  these  conditions  the 
symptoms  may  be  irritative  and  occasionally  slightly  progressive. 

9.  Sensory  disturbances  are  common  in  cases  of  spinal  cord  in- 
jury, though  in  partial  lesions  they  are  usually  less  pronounced 
and  extensive  than  are  the  motor  symptoms.  In  complete  trans- 
verse cord  injuries  anesthesia  develops  immediately  in  the  areas 
supplied  by  the  injured  portion  of  the  cord,  and  in  addition  the 
sensory  function  of  all  Segments  below  the  lesion  is  promptly,  com- 
pletely and  permanently  lost.  This  area  of  anesthesia  is  soon 
followed  by  a  girdle  of  hyperesthesia  representing  two  or  three 
spinal  segments  directly  above  the  injured  region  of  the  cord. 
This  area  of  hyperesthesia  is  the  result  of  irritation  of  the  spinal 
centers  contained  within  the  segments  adjoining  the  lesion,  and 
may  be  the  only  evidence  of  a  hematomyelia  which  so  commonly 


480  FRACTURES   AND   DISLOCATIONS 

develops  in  the  cord  tissue  near  tlic  injury.  Great  sutfering  some- 
times occurs  as  the  result  of  retlex  shooting  pains  tlirougliout  the 
hypei-estlu^tic  area.  This  condition  in  ttie  thoi-aeic  ])07-tion  of  the 
cord  produei's  iiirillc  pains;  in  the  lunihar  t'lihii'iii'iiicut ,  sliooting 
jiains  in  the  lower  extremities  and  genetalia  ;  while  spinal  irritation 
in  tlie  upper  dorsal  or  lower  cervical  segments  of  the  cord  may 
produce  pain  in  the  upper  extremities.  Hyperesthesias  following 
irritation  of  spinal  centers  will  vary  in  degree  and  distrihution  ac- 
cording to  the  region  and  severity  of  the  cord  lesion. 

10.  Distitrhances  in-  reflexes. — In  complete  cord  lesions  the  re- 
flexes below  the  injury  will  be  immediately,  completely  and  perma- 
nently abolished.  Shock,  from  any  cause,  may  produce  temporary 
loss  of  reflexes  which  return,  however,  as  the  patient  recovers. 
Accordingly  too  much  stress  should  not  be  laid  on  their  absence 
immediately  following  the  accident.  In  partial  lesions  the  reflexes, 
dependent  upon  the  damaged  segments,  will  be  lost  or  reduced, 
while  those  below  the  lesion  are  often  absent  immediately  following 
the  accident,  though  they  return  later  and  are  often  increased 
through  lack  of  inhibition  from  the  higher  centers.  When  such 
is  the  case  patellar  and  ankle  clonus  are  present,  together  with 
Babinski's  reflex,  and  other  pathologic  reflexes  of  the  foot  and 
ankle,  indicating  damage  to  the  upper  motor  segment.  The  loss 
of  reflex  activity  is  often  asymmetrical  in,  partial  lesions,  and  cor- 
responds more  or  less  accurately  to  the  distribution  of  motor  and 
sensory  losses.  If  the  reflex  of  a  given  segment  is  increased 
through  spinal  irritation,  spasm,  tremor  or  hyperesthesia  will  prob- 
ably be  present  in  the  corresponding  area. 

11.  The  trophic  disturhances  following  injury  to  the  cord  are 
among  the  most  serious  and  difficult  to  control  of  the  complications 
with  which  we  have  to  contend.  JMost  prominent  among  them  are 
the  bed  .sores  which  develop  where  continued  pressure  is  applied 
to  subcutaneous  bony  prominences,  especially  in  the  region  of  the 
sacrum  and  heels.  The  sacral  sores  are  often  intractable,  rapidly 
attaining  such  size  and  depth  as  to  lay  bare  the  lumbar  and  sacral 
vertebrae,  and  not  infrequently  a  considerable  part  of  the  ossa 
innominata.  When  this  type  of  sore  develops  the  patient  usually 
succumbs  within  a  short  time,  either  from  exhaustion  and  a  general 
septic  condition  or  following  involvement  of  the  exposed  spinal 
membranes.  The  musculature  below  the  seat  of  injury  atrophies 
until  in  extreme  cases  the  outlines  of  the  bones  of  the  lower  ex- 


FRACTURE-DISLOCATIONS   OF    SPINE  481 

tremities  are  apparent  on  inspection.  Contractures  are  common, 
especially  in  the  feet,  which  are  often  depressed  and  in  a  condition 
resembling  that  seen  in  hydrocephalus.  The  bladder  changes  are 
due  partly  to  the  effects  of  retention  following  paralysis,  and 
partly  to  the  disturbed  trophic  supply  of  the  viscus.  Infection  of 
the  bladder,  with  urinary  decomposition,  develops  sooner  or  later 
in  spite  of  the  most  assiduous  care.  This  infection  not  infrequently 
ascends  to  the  kidneys,  ultimately  producing  death. 

The  symptoms  accompanying  fracture-dislocations  of  the  spine 
show  such  variation  in  different  levels  that  for  practical  purposes 
we  will  consider  the  symptoms  peculiar  to  the  different  regions. 

Fracture-dislocations  of  the  cervical  spine  are  often  immedi- 
ately fatal,  especially  when  the  injury  involves  the  upper  four 
vertebrge.  Dislocations  uncomplicated  by  fracture  are  more  com- 
mon here  than  in  other  portions  of  the  spinal  column  (see  "Anat- 
omy," page  465).  The  usual  deformity  is  kyphotic,  though  the  dis- 
placement ioa.a.y,  in  unusual  instances,  be  lateral,  posterior,  rotary 
or  even  overriding.  Unilateral  luxations  are  more  common  in  the 
neck  than  in  other  portions  of  the  spine,  their  usual  seat  being  in 
the  occipito-atlantal  or  in  the  atlo-axial  articulations.  If  death 
does  not  follow  the  injury  within  a  few  hours  motor  and  sensory 
disturbances  develop  in  the  regions  supplied  by  the  injured  spinal 
segments  and  below  the  site  of  the  lesion.  Injuries  at,  or  above, 
the  fourth  spinal  segment  destroy  or  interfere  with  the  nerve  sup- 
ply to  the  diaphragm,  and  the  proximity  of  the  important  centers 
in  the  bulb,  together  with  the  close  association  between  the  pneu- 
mogastric  and  spinal-accessory  nerves,  renders  fractures  in  this 
region  especially  dangerous.  When  death  is  not  immediate  pro- 
nounced variations  are  usually  observed  in  the  temperature,  pulse 
and  respiration.  The  temperature  may  rise  to  105°  or  106°  or 
even  higher,  the  pulse  becoming  rapid  and  arythmic.  The  more 
complete  the  loss  of  function  in  the  phrenic,  the  more  pronounced 
will  be  the  action  of  the  accessory  muscles  of  respiration  provided 
they  are  still  capable  of  action.  Fracture  of  the  cervical  region 
may  involve  the  segments  from  which  the  nerves  of  the  brachial 
are  derived,  and  the  muscles  paralyzed  in  the  upper  extremity 
will  vary  according  to  the  level  of  the  lesion.  AVhen  the  lesion  in- 
volves the  upper  portion  of  the  brachial  plexus  the  upper  extremi- 
ties will  be  held  in  a  characteristic  position  with  the  elbows  flexed, 
and  the  upper  arm  abducted  and  rotated  outward.     Injury  to  the 


482  FRACTTRES    AXO    DISLOCATIONS 

lower  portion  of  tlu'  plexus  produces  a  different  attitude,  with  the 
arms  not  far  from  the  side  and  the  hands  resting  on  the  chest  in 
pronation.  The"  reason  for  these  differences  in  attitude  is  ex- 
plained by  the  formation  and  distribution  of  the  brachial  plexus. 
In  complete  lesions  of  the  cervical  cord  death  almost  invariably 
occurs  within  a  few  hours,  if  not  at  the  time  of  the  accident.  If 
the  patient  survives  the  immediate  effects  of  the  injury  the  usual 
motor  and  sensory  paralyses  develop  below  the  site  of  the  injury, 
including:  loss  of  sphincteric  control.  If  he  lives  a  few  weeks 
tropliie  disturbances  make  their  appearances,  the  most  important 
of  which  is  the  bed  sore. 

Fracture-dislocations  of  the  thoracic  region  are  more  constant 
in  their  type  of  deformity  than  are  corresponding  injuries  in  either 
the  cervical  or  lumbar  spines.  Kyphosis  with  crushing  of  the 
body  of  the  vertebra  is  the  rule.  Fractures  of  the  upper  thoracic 
region  do  not  commonly  influence  motion  or  sensation  of  the  upper 
extremities,  though  the  usual  symptoms  develop  below  the  lesion 
according  to  the  severity  of  cord  injury.  Loss  of  sphincteric  con- 
trol with  sensory  and  motor  disturbances  of  the  legs  and  lower 
trunk  are  present.  Diminished  or  lost  peristalsis  sometimes  results 
in  severe  tympanites  and  fecal  impaction,  through  interference 
with  the  nerve  supply  of  the  intestines.  Any  or  all  of  the  ab- 
dominal viscera  may  show^  diminished  function.  The  thoracic  por- 
tion of  the  spinal  cord  extends  from  the  level  of  the  sixth  cervical 
interspace  to  the  ninth  thoracic  vertebra,  and  hence  fractures  of 
the  spine  below  this  level  involve  the  lumbar  enlargement  or  the 
Cauda  equina  rather  than  the  dorsal  segments. 

Injury  to  the  lumbar  enlargement,  situated  opposite  the  low^er 
three  thoracic  and  first  lumbar  vertebrge,  gives  rise  to  flaccid  pa- 
ralyses of  the  lower  extremities,  varying  in  degree  Avith  the  sever- 
ity of  the  lesion.  The  centers  controlling  the  bladder,  bo^vel  and 
genitalia  are  all  situated  in  this  portion  of  the  cord,  and  hence  dis- 
turbances in  function  occur  in  these  parts  when  this  portion  of 
the  cord  is  injured. 

Injuries  below  the  first  lumbar  vertebra  may  damage  the  nerves 
forming  the  cauda  ecpina ;  the  motor  and  sensory  losses  will  vary 
according  to  the  nerves  injured.  The  reflexes  in  the  lower  ex- 
tremities will  be  lost  if  the  nerves  are  crushed.  Shock  will  be 
much  less  than  that  accompanying  injury  to  the  cord  itself  even 
Avhen  all  the  nerves  are  crushed. 


PRACTURE-DTSLODATTONS   OP    SPINE  483 

Diagnosis.— The  diagnosis  of  fracture  of  the  spine  and  its  com- 
plications, is  based  on  the  symptoms  previously  desfribed.  The 
alignment  of  the  spine  should  be  determined  by  inspection,  and 
the  tips  of  the  spinous  processes  carefully  palpated.  Isolated  frac- 
tures of  the  spines  produce  only  local  pain,  abnormal  mobility, 
and  sometimes  crepitus;  the  symptoms  of  fracture  of  the  spine  as 
a  whole  are  absent.  It  is,  as  a  rule,  an  easy  matter  to  determine 
the  presence  of  fracture  in  the  spinal  column,  although  an  accu- 
rate appreciation  of  the  details  of  the  fracture  is  often  only  had 
by  means  of  the  X-ray  or  at  autopsy.  Unless  the  most  careful 
examination  is  made  in  fractures  without  deformity  the  condition 
may  be  overlooked  and  subsequent  displacement  may  produce  in- 
jury to  the  cord  which  could  have  been  prevented  if  proper  fix- 
ation apparatus  had  been  employed.  The  important  element  in 
fracture  of  the  spine  is  that  of  cord  injury,  the  degree  and  position 
of  which  determine  the  treatment.  Complete  transverse  lesions 
produce  immediate,  total,  permanent  and  symmetrical  loss  of  mo- 
tion, sensation  and  reflexes  below  the  lesion.  Partial  lesions  are 
usually  followed  by  irregular,  incomplete  and  asymmetrical  motor, 
sensory  and  reflex  losses.  The  motor  losses  below  the  lesion  are 
spastic,  while  the  paralyses  in  the  muscles  supplied  by  the  injured 
segments  are  flaccid.  In  complete  lesions  the  motor  losses,  at  and 
below  the  lesion,  are  all  flaccid.  In  cord  injuries,  loss  of  motion 
in  a  single  muscle,  or  group  of  muscles,  never  occurs.  Such  a 
condition  means  injury  to  one  of  the  peripheral  nerves  rather 
than  a  spinal  segment  or  nerve  root.  When  a  spinal  nerve  is 
crushed  in  one  of  the  intervertebral  foramina,  the  motor  and 
sensory  losses  are  conflned  to  the  distribution  of  that  single  nerve 
root.  The  loss  of  reflexes,  accompanying  shock  and  unconscious- 
ness, often  prevents  the  surgeon  from  making  an  early  diagnosis. 
The  degenerative  and  inflammatory  changes  within  the  cord,  fol- 
lowing pressure,  may  begin  within  a  few  hours  of  the  injurj^,  and 
hence  the  value  of  an  early  diagnosis  is  apparent.  The  symptoms 
of  bony  pressure  are  prompt  in  onset,  and  usually  not  progressive, 
while  pressure  due  to  hemorrhage  produces  symptoms  which  in- 
crease in  severity  as  the  blood  escapes  into  or  about  the  cord. 
Pressure  myelitis,  however,  gives  rise  to  symptoms  which  are  prac- 
tically identical  with  those  of  hemorrhage,  and  in  a  given  case  it 
is  not  infrequently  impossible  to  difl^erentiate  between  the  two. 
It  is,  also,  extremely  difficult  in  some  instances  to  differentiate 


484  FRACTURES   AND    DISLOCATIONS 

between   a  partial    K'sion   diu'   to   hoiiy    prcssiire   and   that    due  to 
hemorrhage. 

Tlie  ditifieulties  of  diagnoses  in  tliese  cases  are  greatly  increased 
by  tlie  manner  in  wliich  shock  and  nneonsciousness  sometimes  ob- 
scure the  symi)toins  for  a  nuiuhcr  of  hours  following  the  injury. 
Symptoms  simuhiting  (•oiu[)h4e  lesions  frequently  change  within 
the  first  twenty-four  hours,  being  replaced  by  the  symptoiu-cum- 
plex  of  a  partial  injury.  The  X-ray,  especially  in  stereoscopic 
form,  is  sometimes  of  the  greatest  service  in  determining  the  ex- 
tent to  which  the  lumen  of  the  spinal  canal  has  been  encroached 
upon  by  bony  displacement.  The  level  of  the  cord  lesion  is  de- 
termined by  the  level  of  the  motor  and  sensory  disturbances,  par- 
ticularly the  level  of  the  hyperesthetie  zone  and  the  area  of  flaccid 
paralysis. 

Treatment. — The  treatment  of  fractures  of  the  spine  is  directed, 
firstly,  towards  the  fixation  of  the  injured  portion  of  the  column, 
and  secondly,  to  the  alleviation  of  complications  and  their  symp- 
toms. With  the  exception  of  isolated  fractures  of  the  spinous  or 
transverse  processes  fracture  of  the  spinal  column  calls  for  a 
fixation  in  some  form  regardless  of  v^diether  or  not  the  cord  has 
been  injured.  Fixation  is  most  satisfactorily  accomplished  by 
means  of  a  plaster  cast,  modified  according  to  the  region  of  the 
injury.  In  the  cervical  spine  it  should  be  so  applied  as  to  include 
the  head,  neck  and  shoulders,  leaving  the  arms  free.  In  the  dorsal 
region,  it  will  be  necessary  to  include  the  chest  and  upper  abdomen, 
together  with  the  neck,  if  the  fracture  is  high.  AVhen  the  lower 
dorsal  or  lumbar  vertebra?  are  fractured  the  east  should  extend 
from  below  the  armpits  to  the  hips,  including  the  crests  of  the 
ilia.  In  whatever  region  the  cast  is  applied,  the  deformity  should 
be  previously  corrected  as  perfectly  as  possible,  and  the  patient's 
position  maintained  unchanged  until  the  plaster  has  become  suffi- 
ciently set  to  properly  splint  the  parts. 

Fractures  of  the  cervical  spine  may  be  held  in  reduction  by  the 
hands  of  an  assistant  while  the  cast  is  being  applied.  In  the 
dorsal  and  lumbar  regions,  correction  of  the  deformity  is  much 
more  difficult  because  of  the  weight  and  bulk  of  the  parts  handled. 
Reduction  in  these  portions  of  the  column  may  be  accomplished 
in  a  number  of  ways,  any  of  which  is  satisfactory  if  properly 
performed.  The  possibility  of  producing  cord  or  nerve  injury,  or 
even   death,   while  correcting  the  deformity  should  be   constantly 


FRACTURE-DISLOCATIONS   OP    SPINE  485 

kept  in  mind  during  these  procedures.  AH  manipulations  should 
be  gradual,  gentle,  and  guarded  and  the  greatest  care  exercised  in 
moving  the  patient  to  avoid  strain  or  further  displacement  of  the 
injured  portions  of  the  spine. 

If  the  patient  is  placed  on  two  tables,  face  downward,  and  the 
tables  so  separated  that  the  body  sags  downward  between  them,  the 
deformity  will  not  uncommonly  be  reduced  without  further  ma- 
nipulation. Gentle  pressure  over  the  prominent  spines  may  be 
necessary  in  addition  to  secure  proper  relations  of  the  fragments. 
Two  or  three  assistants  will  be  necessary  to  securely  hold  the  pa- 
tient at  the  shoulders  and  heels  to  prevent  his  slipping  off  the 
tables,  and  to  maintain  the  proper  degree  of  spinal  curvature. 
In  this  position  the  surgeon  may  begin  the  application  of  the  plas- 
ter bandages,  the  skin  of  the  trunk  having  been  previously  pro- 
tected by  means  of  a  snug,  soft  woven  shirt.  Another  method 
consists  in  suspending  the  patient  in  a  hammock,  and  so  regulating 
the  tension  at  which  the  hammock  is  hung  that  the  proper  spinal 
curvature  is  obtained,  and  the  deformity  corrected.  The  Brad- 
ford-Lovett  hammock  frame  is  an  excellent  apparatus  in  the  appli- 
cation of  a  cast  of  this  kind.  It  matters  little  how  the  cast 
is  applied  provided  the  following  essentials  are  observed :  The 
deformity  should  be  corrected ;  the  cast  should  be  sufficiently  heavy 
to  withstand  the  subsequent  strain;  it  should  possess  some  non- 
irritating  lining  and  should  so  secure  the  trunk  that  the  spine  is 
immobilized.  A  stomach  pad  consisting  of  two  or  three  folded 
towels  should  be  placed  over  the  abdomen,  before  the  plaster  is 
applied  and  removed  when  the  cast  is  completed.  This  allows 
room  for  comfortable  respiration  and  eating  during  the  after- 
treatment.  It  is  essential  that  the  cast  remain  exposed  to  the  air 
(not  covered  with  bed  clothes)  for  twenty-four  hours,  or  until  the 
plaster  has  thoroughly  set  and  dried. 

Immobilization  of  the  spine  may  be  accomplished  in  other  ways 
besides  the  plaster  cast,  though  probably  not  any  more  satisfactorily 
in  the  usual  case.  Steel  braces,  similar  to  those  employed  in  the 
treatment  of  Pott's  disease,  may  be  used  in  fixing  the  spine. 

The  water  bed  has  been  much  used  in  the  treatment  of  these 
eases,  though  the  fixation  of  recumbency  alone  is  by  no  means  as 
efficient  as  that  produced  by  the  cast  or  brace.  In  the  early  treat- 
ment of  fracture  of  the  spine,  extension  and  counter-extension  may 
be  employed  by  means  of  Buck's  apparatus  applied  to  both  legs 


486  FRACTURES   AND   DISLOCATIONS 

Avitli  tile  foot  of  the  lied  raised.  Saiul  bags  about  tlie  body  serve 
to  steady,  the  parts,  and  a  small,  hard  pillow  under  the  small  of 
the  back  will  n>aiiitain  the  proper  dorsal  curvature.  The  Bradford 
frame  uuiy  be  used  to  advantage  when  simple  recumbency  is  the 
nu'thod  of  fixation. 

If  the  fracture  is  complicated  by  cord  or  nerve  injury,  liic  indi- 
cations to  be  met  in  the  treatment  are  much  more  complex.  In 
addition  to  fixation  of  the  spine,  the  relief  of  symptoms  resulting 
from  the  complication  is  demanded  as  far  as  may  be  possible. 
This  inay,  or  may  not,  require  operation.  When  an  absolute  diag- 
nosis of  complete  crushing  to  the  cord  can  be  made,  operation  is 
contraindicated,  since  it  can  do  no  good.  In  partial  lesions  we 
should  open  the  spinal  canal  at  the  seat  of  injury  for  the  removal 
of  such  pressure  as  may  be  present.  Fractures  of  the  spine  below 
the  cord,  with  symptoms  of  injury  to  the  cauda  equina,  call  for 
operation. 

Operative  Treatment. — The  question  of  when  to  operate  and 
when  to  treat  the  patient  expectantly  has  been  the  subject  of  much 
discussion.  At  the  present  time,  however,  it  is  commonly  agreed 
by  most  surgeons  that  complete  crushing  injury  to  the  cord  should 
not  be  operated  because  of  the  hopelessness  of  the  condition.  The 
difficulty  in  determining  when,  and  when  not,  to  operate  in  a  given 
case  arises  from  the  difficulty  of  an  accurate  diagnosis  of  the  con- 
dition of  the  cord.  Partial  lesions  to  the  cord  and  injuries  to  the 
Cauda  equina  demand  oi)erative  intervention  in  almost  all  cases. 
The  peculiarities  of  each  individual  case,  however,  must  be  consid- 
ered by  themselves,  and  complicating  conditions  such  as  shock  and 
injuries  to  other  portions  of  the  body,  especially  the  skull,  neces- 
sarily modify  the  indications  for  operation  and  the  best  time  for 
its  performance.  Compound  fractures  of  the  spine  invariably  call 
for  surgical  measures.  The  objects  for  which  operation  is  per- 
formed, are:  the  correction  of  deformity,  decompression  of  the 
cord,  suture  of  nerves,  and  the  treatment  of  the  wound  in  com- 
pound cases. 

The  permanency  of  the  sensory  and  motor  losses  determines  the 
completeness  of  the  cord  injury,  but  when  operation  is  delayed 
for  a  few  days  to  establish  the  diagnosis,  the  prognosis  in  partial 
lesions  is  rendered  much  w^orse  by  the  development  of  pressure 
myelitis,  and  other  degenerative  processes  within  the  cord.  For 
this  reason  some  surgeons  maintain  that  the  spinal  canal  should 


FRACTURE-DISLOCATIONS   OF<^    SPINE  487 

be  opened  in  practically  all  instances  complicated  by  cord  injury, 
for  the  sake  of  removing  pressure  in  partial  lesions  which  could 
not  be  otherwise  differentiated  from  total  crushes.  If  we  follow 
this  principle,  we  must,  of  necessity,  submit  many  cases  of  com- 
plete crushing-  to  operation  for  the  sake  of  relieving  pressure  in 
instances  in  which  the  lesion  proves  to  be  only  partial.  The  ques- 
tion might  then  be  asked,  and  not  without  reason,  "What  harm 
has  been  done  by  operating  upon  complete  lesions  when  they  are 
hopeless  from  the  first?"  Spinal  decompression  is  by  no  means 
as  successful  as  might  be  wished,  yet  if  only  a  moderate  degree 
of  improvement  results  the  operation  is  justified.  The  state  of 
the  patient,  even  though  he  be  confined  to  a  wheel  chair  is  much 
more  tolerable  than  when  he  is  completely  bedridden  and  unable 
to  help  himself. 

The  spinal  canal  may  be  opened  by  simple  laminectomy,  or  by 
means  of  an  osteoplastic  resection.  In  performing  a  laminectomy, 
a  median  incision  four  or  five  inches  long  is  made  in  the  region 
of  the  injury.  The  muscles  are  separated  from  the  spines  and 
laminae  on  either  side,  preferably  by  blunt  dissection.  If  hemor- 
rhage proves  troublesome  one  side  should  be  packed  with  gauze, 
while  the  other  is  being  worked  upon.  It  is  next  determined  how 
many  sets  of  spines  and  laminae  are  to  be  removed  to  properly 
expose  the  region  of  injury.  The  supra-  and  inter-spinus  liga- 
ments and  ligamentum  subflavum  are  then  divided  below  the  low- 
est spine  to  be  removed  and  above  the  uppermost  pair  of  laminse 
to  be  included  in  the  resection.  Care  should  be  taken  not  to 
introduce  the  scalpel  too  far  in  dividing  the  ligaments  lest  injury 
be  inflicted  on  the  contents  of  the  neural  canal.  The  laminge  are 
next  divided  near  their  junction  with  the  transverse  processes  by 
means  of  a  saw,  chisel  or  heavy  bone  cutting  forceps,  after  which 
the  osteo-ligamentous  section  is  removed,  exposing  the  dura.  The 
theca  is  then  opened  by  immediate  incision,  and  the  cord  and  its 
nerves  examined.  Inspection  and  palpation  will  disclose  the  na- 
ture and  degree  of  pressure  on  the  cord,  together  with  the  second- 
ary changes  which  may  have  occurred.  Pressure  may  be  relieved 
in  some  instances,  by  simply  correcting  the  deformity  in  the  column, 
or  it  may  necessitate  the  chiseling  away  of  bony  prominences  or 
the  removal  of  fragments.  Hemorrhage  about  the  cord  is  readily 
recognized  when  the  dura  is  exposed  and  opened.  Hemorrhage 
into  the  substance  of  the  cord  gives  a  distended,  swollen  appear- 


488 


KKACTIUKS    AXI>    DISLOCATIONS 


iiucv.  ll  is  j)rol)al)ly  wise  to  di'jiiii  tlic  (•(intents  ol'  liciiuitoinyclia, 
though  this-  proeeduiv  has  not  liccn  pcrfoi-iiu'd  sufticiciitlN'  often  to 
l)ei"init  of  trust\Vorthy  eonelu.sions.  'I'tie  renio\al  ol'  .spines  and 
lainiuas  leaves  a  defieienc}'  in  the  s|iinal  coluinn.  yet  ilisturbances 
in  function  resulting  from  tliis  loss  are  extremely  rare.  Laiui- 
nectoniy  produces  greater  injury  to  the  circulation  than  occurs 
in  an  osteoplastic  resection,  yet  it  has  other  advantages  which  more 
than  make  up  for  the  difference.  When  the  normal  anatomic  re- 
lations ai'e  disturbed  by  fracture  or  dislocation,  it  is  safer  to  expose 
the  lamina?  before  dividing  them ;  there  is  less  danger  of  injury 


Fig.   560. — Methods  of  wiring  the  processes  togetlier  sometimes  employed  in  operating 
on  fractures  of  the  spine. 

to  the  contents  of  the  canal  if  the  bony  landmarks  are  exposed  and 
the  deformity  accomi^anying  the  fracture  fully  appreciated. 

In  opening  the  spinal  canal  by  the  o-steoplastic  method  a 
U-shaped  incision  is  made,  the  vertical  arms  of  which  are  parallel 
to  the  spinous  processes  in  the  region  of  the  injury.  The  soft  tis- 
sues are  divided  by  a  deep  incision,  down  to  the  laminae.  The 
ligaments  are  then  divided  transversely  between  two  vertebrae  below 
the  seat  of  the  fracture  as  described  in  laminectomy.  The  laminte 
are  then  cut  on  either  side  near  their  junction  with  the  pedicles, 
a  sufficient  number  of  arches  being  divided  to  turn  four  or  five 
spines  upward  in  the  osteoiilastic  flap.  When  this  operation  is 
done  in  the  dorsal  region,  where  the  spines  are  imbricated,  it  may 


FRACTURE-DISLOCATIONS   OP    SPINE 


489 


be  necessary  to  remove;  the  ti])  of  the  vertebral  spine  just  aljove 
the  base  of  the  flap  before  the  latter  can  be  turned  back.  This  is 
best  accomplished  through  a  short,  median  incision  over  the  spine 
to  be  removed  (see  Fig.  561).  After  the  deformity  has  been  cor- 
rected, and  the  pressure,  whether  due  to  bone  or  blood,  removed, 
the  flap  is  sutured  in  position,  with  drainage  in  the  lower  angle. 
It  is  usually  necessary  to  apply  a  cast  to  maintain  reduction. 

When  injuries  to  the  cord  exist  nothing  can  be  done  which  will 
be  followed  by  regeneration  in  the  destroyed  cells  or  tracts,  yet 


Fig.  561. — Lines  indicating  the  incisions  used  in  operations  on  the  spine.  A.-B., 
median  incision  employed  in  laminectomy.  The  loop  CD.  is  used  in  an  osteoplastic 
flap.  Tlie  incision  E.-F.  is  made  to  divide  the  spinous  process  above  tlie  flap  so  the 
flap  may  be  turned  back. 

deformity  should  be  corrected  and  pressure  removed  to  avoid  the 
subsequent  development  of  secondary  complications.  If  spinal 
nerves  are  divided  they  call  for  suture,  in  addition  to  the  removal 
of  pressure. 

There  is  no  established  technique  or  mode  of  procedure  in  oper- 
ating upon  fractures  of  the  spine.  The  findings  in  a  given  case 
will  point  out  the  indications.  The  operations  just  described  are 
for  the  purposes  of  relieving  cord  and  nerve  injuries,  and  have 
little  to  do,  primarily,  with  the  correction  and  fixation  of  the  de- 
formity.    Operation  for  these  purposes  alone  is  only  rarelj'  found 


490  FRACTURES   AND   DISLOCATIONS 

necessary.  If  an  iiiie-oiuplicateil  ItacluiL'  of  the  spine  exists,  with 
])ronounced  tendency  to  the  recurrence  of  deformity  following  re- 
duction, we  may  be  justified  in  exposing  the  spines  and  laminae 
with  a  view  to  fixing  tiiem  by  means  of  wire  as  described  by  Hadra. 
The  essentials  of  the  method  consist  in  securing  sound  spines  above 
tlie  injury  to  those  below  the  seat  of  fracture,  by  means  of  silver 
wire  (see  Fig.  560). 

After-Treatment. — The  after-treatnicnt  iu  fractures  of  the  spine 
is  directcil  firstly,  to  uuiintaining  fixation  of  the  fracture,  and 
secondly,  to  the  symptonuitic  treatment  of  disturbances  resulting 
from  cord  or  nerve  injury.  The  apparatus  used  for  fixing  the 
spine  whether  cast,  brace,  extension  or  other  apparatus,  should  be 
carefully  inspected  from  day  to  day  to  avoid  irritation  of  the  soft 
parts  which  so  often  results  in  the  development  of  sluggish  sores. 
This  applies  to  any  form  of  fixation  appliance  employed  in  the 
treatment  of  fracture,  but  especially  in  complicated  fractures  of 
the  spine  when  anesthesia  and  the  loss  of  the  protective  pain  sense, 
together  with  disturbed  trophic  supply  favors  the  development  of 
sores  and  extensive  sloughs  without  the  patient  realizing  his  con- 
dition. The  buttocks  and  heels  require  especial  care  to  prevent 
the  development  of  bed  sores.  A  pneumatic  ring  may  be  used  to 
relieve  the  sacral  region  from  pressure,  and  pads  of  cotton  may 
be  placed  under  the  tendo-achillis  to  prevent  the  heel  resting  on 
the  bed.  These  parts,  especially,  should  be  bathed  in  alcohol  twice 
daily  if  the  slightest  evidence  of  skin  irritation  is  present.  The 
perineal  and  gluteal  regions  should  be  kept  scrupulously  clean  to 
prevent  irritation  from  urine  and  feces. 

One  of  the  most  discouraging  conditions  with  which  we  have  to 
contend  is  that  of  cystitis  which  almost  invariably  develops  fol- 
lowing the  repeated  use  of  the  catheter.  It  is  needless  to  say  that 
the  most  strict  aseptic  precautions  should  be  observed  if  cathe- 
terization is  found  necessary.  It  is  advisable,  when  possible,  to 
rely  on  the  bladder's  emptying  itself,  even  when  a  moderate  de- 
gree of  urinary  distention  is  present.  Gentle  massage  of  the  dis- 
tended viscus  will  often  result  in  a  fairly  satisfactory  evacuation 
of  the  bladder,  and  although  this  method  is  by  no  means  ideal,  yet 
it  is  far  better  to  get  along  in  this  way  than  to  resort  to  the 
catheter  with  its  almost  inevitable  train  of  disastrous  results  fol- 
lowing infection  of  the  genito-urinary  tract.  If  the  bladder  be- 
comes infected  during  the  after-treatment,  it  is  often  best  to  estab- 


FRACTURE-DISLOCATIONS   OP    SPINE  491 

lish  permanent  drainage  to  control  the  condition.  Suprapubic 
cystotomy  may  be  performed  and  a  suction  af)paratus  employed 
to  keep  the  bladder  empty.  This  is  probably  as  satisfactory  a 
method  as  any  of  dealing  with  infection  of  the  bladder  under  these 
circumstances.  "When  analgesia  is  present  in  the  hypogastric 
region,  the  operation  may  be  performed  without  an  anesthetic. 
The  bladder  should  be  washed  at  least  once  daily  with  a  boric  acid 
or  potassium  permanganate  solution.  Some  surgeons  prefer  peri- 
neal drainage.  Permanent  catheterization  has  been  employed  with 
success,  though  the  urethra  will  not  tolerate  the  presence  of  a 
foreign  body  indefinitely.  The  intermittent  use  of  hexamethylene- 
tetramine  will  be  found  of  service  in  dealing  with  infection  of  the 
genito-urinary  tract. 

Obstipation  and  fecal  impaction  sometimes  accompany  fracture 
of  the  spine,  and  must  be  dealt  with  by  laxatives,  enemata,  mas- 
sage, and  in  some  instances  mechanical  removal  of  the  impacted 
material. 

The  condition  of  some  of  these  patients  is  so  obviously  hopeless 
that  it  is  often  wise  to  make  them  comfortable  even  though,  in 
some  respects,  it  may  be  at  the  expense  of  their  physical  welfare. 
Severe  shooting  pains  in  the  hyperesthetic  areas,  when  severe,  call 
for  the  exhibition  of  opiates. 

Prognosis. — The  outlook  in  uncomplicated  fractures  of  the  spine 
is  good,  especially  when  a  fair  reduction  of  the  deformity  has  been 
accomplished.  When,  however,  injuries  to  the  spinal  cord  accom- 
pany the  fracture,  the  prognosis  is,  at  best,  discouraging.  There 
will  be  permanent  loss  of  function,  the  degree  varying  with  the 
extent  of  the  injury,  and  the  improvement  which  takes  place  in 
these  cases  is  usually  too  trifling  to  be  of  real  importance.  Cases 
of  partial  injuries  to  the  cord  which  survive  the  immediate  effects 
of  the  accident,  lead  a  life  of  invalidism  varying  from  a  few  months 
to  a  few  years.  Cases  of  complete  crushing  of  the  cord  seldom 
live  more  than  a  few  months.  Death  usually  follows  as  a  result 
of  some  intercurrent  condition,  such  as  infection  of  the  genito- 
urinary tract,  meningitis,  septic  states,  pneumonia,  etc.  The  lower 
the  injury  in  the  spine,  the  better  the  prognosis.  Operation  is 
of  no  avail  in  complete  crushing  injuries,  although  it  renders  the 
prognosis  much  more  favorable  in  partial  lesions  especially  when 
done  within  a  few  hours  of  the  injury. 


CHAPTER  XXXV. 

KKACTrRES  AND  DISLOCATIONS  OF  THE  PELVIS. 

Surgical  Anatomy.  TIr-  pelvis  is  ori<iiiially  made  \\p  oi"  fifteen 
bones;  three  in  either  os  innorainatnin,  five  in  the  sacrum  and  four 
in  the  coeeyx.  AVhen  ossification  is  comph'te  we  have  hut  four, 
including  the  coccyx  which  is  attached  to  the  lower  end  of  the 
sacrum.  The  pelvis  has  fifty-five  centers  of  ossification,  some  of 
which  are  of  surgical  importance.  The  os  innominatum  has  three 
l)iiinary  centers,  one  for  each  of  the  three  bones  entering  into  its 


Fig.  562. — The  pelvis.  S.,  Symphysis  pubis;  P.,  Body  of  pubis;  A.R..  .Vscendinp: 
ramus;  J.-P.R.,  Isehio-pubic  rami;  I.,  Ischium;  A.  Acetabulum;  A.S'./.,V.,  Anterior- 
superior  iliac  spine;  A.I.I.S.,  Anterior-inferior  iliac  spine.  Lumbar  and  sacral  verte- 
bra' numbered  in  order. 

formation.  The  ilium,  ischium  and  pubis  meet  in  the  acetabulum, 
and  prior  to  the  fusion  of  these  three  bones  they  are  separated  by 
a  Y-shaped  cartilage.  A  blow  on  the  trochanter  therefore,  may 
break  the  os  innominatum  into  its  three  anatomical  parts,  the  in- 
jury resembling  the  epiphyseal  separations  seen  elsewhere  in  the 
long  bones.  The  three  bones  become  united  at  about  the  seven- 
teenth year,  after  which  this  injury  cannot  take  place.     The  entire 

492 


FRACTURES    AND    DISLOCATIONS    OF    PKLVIS  493 

crest  of  the  ilium  may  ])e  separated  as  an  ('])iphy.sis,  or  its  anterior 
portion  may  be  pulled  away  hy  nniseular  aetion  j)rior  to  the  twen- 
ty-fourth year,  at  which  time  it  joins  the  rest  of  the  ilium.  The 
epiphysis  of  the  anterior  inferior  iliac  spine  has  been  avidsed  by 
the  action  of  the  straight  head  of  the  rectus  femoris,  and  by  trac- 
tion transmitted  to  it  through  the  Y-ligament  of  Bigekjw.  TJie 
development  of  the  sacrum  is  also  of  interest  in  this  resi)ect ;  the 
lateral  surfaces  of  the  bone  are  ossified  by  plates  which  are  in 
reality  epiphyses.  Fracture  in  this  region  will  find  the  plane  of 
least  resistance,   often   following   the   epiphyseal   cartilages   rather 


Pig.  563. — Lateral  view  of  pelvis.  A.S.I.S.,  Anterior-superior  iliac  spine;  A  1 1  S.. 
Anterior-inferior  iliac  spine;  G.M.,  Gluteus  Maxinuis;  G.Mpd..  Gluteus  medius:  Ghiteiis 
min.,   Gluteus  minimus;    A.,  Acetabulum;    S.M.,   Semimemhranosus ;   B.,   Biceps. 

than  the  articulation  itself.     Fracture  of  the  incompletely  ossified 
sacrum  follows  the  cartilage  rather  than  the  bone. 

The  ossa  innominata  transmit  the  weight  of  the  body  from  the 
spine  to  the  femora  in  the  erect  posture,  or  to  the  tubera  ischiorum 
in  the  sitting  position.  The  sacrum,  together  with  that  portion 
of  the  ossa  innominata  behind  the  acetabula,  forms  an  arch  for 
the  transmission  of  weight  to  the  femora ;  another  arch  with  the 
tubera  ischiorum  as  the  base  transmits  the  weight  from  the  spine 
to  the  object  on  which  the  person  sits.  The  anterior  portion  of 
the  pelvis  is  composed  of  the  pubes,  and  the  rami  which  connect 
them  above  and  below  the  thyroid  foramina  with  the  remainder 
of  the  pelvis.     This  part  of  the  pelvis  is  composed  of  two  counter- 


494 


FRACTURES   AND   DISLOCATIONS 


arches  for  the  support  of  the  two  main  arches  just  described.  The 
pubes  and  two  ascending;  rami  constitute  the  upper  counter-arch, 
reonforcing  tlie  main  arch  which  transmits  the  weight  to  tlie  femora ; 


Fig.    564. — Fracture    of    the    pelvis    througli    the    bottom    of    the    acL'tubuluiii    due    to 
trauma  transmitted  through  the  femur. 

while  the  pubes  and  two  ischiopubic  rami  form  the  counter-arch 
for  the  main  arch  having  its  base  in  the  two  tubera  ischiorum. 
The  anterior  portion  of  the  pelvis  is  much  lighter  than  the  pos- 
terior and  more  frequently  fractured.     The  main  arches  are  very 


FRACTURES    AND    DISI.OCATIONS    OF    PELVIS  495 

strong  and  it  not  infrequently  happens  that  the  connter-arehes  are 
fractured  by  excessive  strains  which  have  been  applied  to  the  main 
arches,  without  however  breaking  the  latter.  When  antero-pos- 
terior  force  is  applied  the  anterior  portion  of  the  pelvis  gives  way 
first,  and  then,  if  the  force  continues  to  act,  the  lateral  portions 
of  the  pelvis  are  forced  apart  and  there  is  likely  to  be  injury  in 
the  region  of  the  sacro-iliac  joints.  Transverse  violence  breaks 
the  counter-arches  forcing  them  forward,  after  which  the  main 
arches  give  way  and  we  have  fracture  of  the  lateral  portions  of 
the  pelvis  or  in  the  region  of  the  sacro-iliac  synchondrosis.  In  the 
first  instance  fracture  of  the  anterior  portion  is  by  direct  violence, 
while  the  second  is  by  indirect  violence.  The  action  of  violence 
on  the  pelvis  might  be  likened  to  the  mechanism  of  fracture  of  the 
skull,  which  results  in  fracture  "by  bending"  and  fracture  "by 
bursting. ' '  Isolated  fracture  of  the  posterior  portion  of  the  pelvis 
only  occurs  in  the  presence  of  well  localized  and  severe  trauma. 
Numerous  muscles  are  attached  to  the  surface  of  the  pelvis,  both 
internally  and  externally,  and  these  muscles  each  have  a  displacing 
tendency  when  fracture  is  present.  Their  origins  and  insertions 
should  be  understood  in  order  that  we  may  appreciate  their  influ- 
ence on  deformity. 

To  the  crest  of  the  ilium  we  have  the  erector  spinas,  the  latissimus 
dorsi,  quadratus  lumborum,  external  oblique,  internal  oblique  and 
transversus  abdominalis,  tensor  vaginae  femoris  and  sartorius. 
These  muscles,  with  the  exception  of  the  last  two,  pull  in  an  up- 
ward, or  upward  and  inward  direction,  while  the  last  two  pull 
downward  toward  the  thigh.  The  external  surface  of  the  ilium 
affords  attachment  to  the  three  gluteal  muscles,  while  the  inner 
surface,  above  the  brim  of  the  true  pelvis,  is  taken  up  by  the 
origin  of  the  iliacus.  The  pubis  affords  attachment  to  the  con- 
joined tendon  of  the  internal  oblique  and  transversalis,  the  tendon 
of  the  external  oblique,  rectus  and  pyramidalis.  All  the  muscles 
of  this  group  pull  upward,  or  upward  and  outward.  The  anterior 
surface  of  the  pubis  and  the  ischiopubic  rami  afford  attachment 
to  the  adductor  muscles ;  the  tuber  ischii  to  the  semimembranosus, 
semitendinosus  and  the  biceps,  all  of  which  have  a  downward  pull. 
When  the  fragment  is  free  the  tendency  is  toward  displacement  in 
the  line  of  pull  of  the  muscle  attached.  The  vascular  and  nervous 
structures  passing  under  Poupart's  ligament  lie  close  to  the  ascend- 
ing ramus  of  the  pubis  and  may  be  injured  by  displaced  fragments. 


496  FRACTURES   AXD   DISLOCATIONS 

AVc  have  tlie  internal  piulie  artery  nmniiip:  on  the  inner  surface 
(if  the  isehiopubie  rami  where  it  may  he  injured  when  tliis  portion 
of  the  pelvis,  is  fraetiiied.  The  sti'uetures  passing  through  the 
greater  and  lesser  sciatic  foramina  are  also  to  be  consider(>d  in 
fracture  of  the  posterior  portion  of  the  pelvis. 

The  bladder  lies  behind  the  pnbes  and  is  more  or  less  attached 
to  the  bones  by  tibrons  tissue;  it  may  be  injured  by  compression 
wlieii  the  viscus  is  full,  by  the  penetration  of  fragments  or  by  the 
l)ull  of  tlie  connective  tissue  when  portions  of  the  bone  are  dis- 
placed. 'J'he  two  layers  of  the  triangular  ligament,  composed  of 
heavy  fibrous  tissue,  are  firmly  attached  to  the  isehiopubie  rami 
which  form  the  subpubic  arch.  When  this  arch  is  fractured  the 
ligament  is  usually  torn  and  since  the  urethra  passes  through  the 
ligament  it  may  also  suflfer  injury.  The  rectum  is  situated  in  the 
posterior  portion  of  the  pelvis,  follows  the  curve  of  the  anterior 
surface  of  the  sacrum  and  coccyx,  and  in  this  protected  position 
is  rarely  injured.  The  nerves  passing  through  the  sacrum  and 
in  close  relation  to  the  coccyx  may  be  injured  when  this  region  of 
the  pelvis  is  fractured. 

Etiology. — Fracture  of  the  pelvis  is  usually  the  result  of  great 
violence  such  as  occurs  when  the  patient  is  caught  between  two 
railroad  cars  or  crushed  beneath  falling  rock  in  mine  accidents. 
Falls  from  heights  may  produce  the  condition,  the  force  often  being 
transmitted  through  the  femora  or  tubera  ischioinim.  Fracture  of 
the  pelvis  is  comparatively  a  rare  accident,  constituting  about  one- 
half  percent  of  all  fractures.  The  flaring  ilia  are  more  frequently 
fractured  than  is  the  true  pelvis  because  of  their  lighter  structure 
and  more  exposed  positions. 

Classification  and  Pathology. — The  pelvis  is  a  complex  structure 
both  ill  its  bony  parts  and  its  relation  to  viscera.  The  different 
portions  of  the  pelvis  should  be  studied  individually,  and  then  the 
pelvis  as  a  whole  is  to  be  considered  with  reference  to  its  various 
functions.  Like  the  skull,  the  most  important  feature  of  fracture 
of  the  pelvis  consists  of  the  injury  which  may  be  sustained  by 
adjacent  soft  tissues,  in  other  words  the  complications  occurring 
in  fracture  of  the  pelvis  are  far  more  serious  than  the  fracture 
itself. 

Fracture  of  the  pelvis  may  be  divided  clinically  into  complicated 
and  nncompJicatrd  cases.  Uncomplicated  fracture  commonly  oc- 
curs in  isolated  fracture  of  some  one  of  the  three  bones  forming 


FRACTURES   AND    DTSTjOCATIONS   OF   PF.LVIS  497 

the  OS  innorainatum  while  the  complicated  type,  is  most  commonly 
seen  when  the  pelvic  girdle  is  fractured. 

Uncomplicated  fracture  most  frequently  occurs  in : 

1.  The  upper  expanded  portion  of  the  ilium. 

2.  The  rim  of  the  acetabulum. 

3.  The  tuberosity  of  the  ischium. 

4.  The  coccyx  and  tip  of  the  sacrum. 

The  complicated  type  is  represented  by : 

1.  Separation  of  the  symphysis  pubis. 

2.  Fracture  of  the  pubic  and  ischiopubic  rami. 

3.  Vertical  fracture  of  the  lateral  portions  in  the  region  of 

the  acetabulum. 

4.  Separation  of  the  sacro-iliac  joints. 

5.  Transverse  fracture  of  the  sacrum. 

Considerable  useless  distinction  has  been  made  between  fracture 
and  dislocation  of  the  pelvis.  Probably  the  only  real  dislocation 
occurring  in  the  pelvis  is  that  of  the  coccyx.  The  so-called  dislo- 
cations described  as  having  taken  place  in  the  sacro-iliac  synchon- 
drosis are  at  most  only  subluxations,  usually  complicated  by  frac- 
ture in  the  immediate  neighborhood  of  the  joint.  In  most  of  the 
reported  cases  of  sacro-iliac  dislocation  fracture  has  been  recog-. 
nized  as  a  complication  and  in  other  instances  the  report  would 
indicate  that  the  presence  of  fracture  had  not  been  properly  ex- 
cluded by  X-ray  examination.  Separation  of  the  symphysis  may 
be  considered  as  a  dislocation  though  it  is  probably  more  in  ac- 
cordance with  the  pathological  facts  to  place  it  under  the  heading 
of  fractures. 

Symptoms. — The  symptoms  of  fracture  of  the  pelvis  will  vary 
according  to  the  region  of  the  injury  and  the  complications  present. 
Isolated  fracture  of  a  small  portion  of  the  pelvis  such  as  the 
anterior  superior  iliac  spine  will  not,  as  a  rule,  give  rise  to  more 
than  local  symptoms.  There  will  be  more  or  less  localized  pain 
which  is  increased  when  the  patient  moves  about.  On  examination 
we  find  abnormal  mobility,  crepitus,  tenderness,  swelling,  etc. 
But,  on  the  other  hand,  when  the  pelvic  girdle  is  fractured  and 
complications  are  present,  we  have  a  very  different  clinical  picture. 
Shock  is  a  prominent  symptom  as  evidenced  by  pallor,  cold  clammy 
skin,  weak  rapid  pulse,  etc.     Collapse  and  unconsciousness  may 


498  FRACTURES   AND   DISLOCATIONS 

supervene  in  ]»i<)iiouiiee(l  eases.  If  eoiiscioiis  the  patient  suffers 
intense  pain  and  deformity  of  the  true  pelvis  is  present  to  a  greater 
or  less  degree.-  It  is  often  possible  to  elicit  abnormal  mobility 
and  crepitus  upon  examination  though  the  surgeon  should  exer- 
cise the  greatest  care  to  avoid  further  injury  to  the  viscera  by 
manipulation.  Inability  to  walk  may  be  due  to  pain,  shock  and 
visceral  injury  or  it  may  be  the  result  of  mechanical  disturbance 
in  the  weight-carrying  function  of  the  pelvis.  If  that  portion  of 
the  pelvis  bearing  the  acetabulum  is  displaced  upward  there  will 
be  shortening  in  the  lower  extremity  of  the  same  side.  To  these 
symptoms  will  be  added  those  peculiar  to  the  complications  present. 

Of  the  uncomplicated  fractures  of  the  pelvis,  isolated  fracture 
of  the  upper  expanded  portion  of  the  ilium  is  the  most  common, 
while  fracture  of  the  anterior  portion  of  the  pelvic  ring  is  the  most 
frequent  representative  of  the  complicated  type. 

The  symptoms  occurring  in  the  different  types  of  uncomplicated 
fracture  of  the  i)elvis  are  as  follows : 

1.  Fracture  of  the  upper  expanded  portion  of  the  ilium  will  be 
accompanied  by  pain  in  the  region  of  the  injury,  tenderness  and 
often  swelling.  Ecchymosis  frequently  develops  after  the  first 
twelve  or  twenty-four  hours.  Pain  will  be  increased  by  any  motion 
which  calls  into  activity  the  muscles  attached  to  the  fragment  or 
fragments.  "When  the  course  of  the  fracture  is  horizontal  the 
crest  may  show  marked  upward  displacement.  The  line  of  frac- 
ture will  frequently  be  found  running  downward  and  forward  from 
the  middle  of  the  crest,  or  less  commonly  downward  and  backward 
from  the  same  point.  The  fracture  is  usually  due  to  direct  violence 
and  accordingly  bruises  or  abrasions  are  frequently  seen  in  the 
skin  over  the  region  of  injury.  In  rare  instances  the  intestines 
lying  in  the  hollow  of  the  ilium  may  suffer  injury,  producing  symp- 
toms of  shock  and  peritonitis.  When  the  fracture  is  confined  to  the 
region  of  the  anterior  superior  iliac  spine  the  fragment  may  be  dis- 
placed forward  and  outw^ard  due  to  the  combined  actions  of  the 
abdominal  muscles,  sartorius  and  tensor  vaginae  femoris.  When 
the  fragment  includes  only  a  small  part  of  the  crest  and  only  a  small 
portion  of  the  abdominal  muscles  are  attached,  the  action  of  the 
thigh  muscles  just  mentioned  will  be  practically  unopposed,  resulting 
in  doAvnward  displacement. 

Crepitus  is  usually  present  but  is  by  no  means  constant,  since 
the  fragments  are  not  alwa^-s  in  contact.     Relaxation  of  the  muscles 


FRACTURES    AND    DISUOfiATIONS    OF    PELVIS 


499 


of  the  abdomen  and  thigh  will  render  palpation  of  the  fragments 
easier  and  often  enable  the  snrgeon  to  elicit  crepitus  which  would 
otherwise  be  absent.  This  may  be  accomplished  by  placing  pillows 
beneath  the  patient's  shoulders  and  flexing  the  thighs. 


Fig.    566. 

rigs.  565  and  566. — Fracture  of  the  left  ilium  with  tearing  away  of  the  abdominal 
muscles  from  the  iliac  crest.  Note  the  change  in  outline  with  the  patient  in  the 
lateral  recumbent  position.  (Atrophy  of  right  thigh  result  of  old  amputation  of  right 
leg.) 


2.  Fracture  of  the  rim  of  the  acetabulum  does  not  occur  except 
as  a  complication  of  displacements  of  the  head  of  the  femur.  The 
upper  posterior  part  of  the  rim  is  the  portion  of  the  acetabular  cir- 


500  FRACTURES   AND    Dl.SlA)CATlOXS 

cuiiifeivnce  most  frtHiuently  detached  by  the  head  of  the  femur  as 
it  leaves  the  cavity.  Fracture  of  the  rim  of  the  acelabuhuu  with 
displacement  of  the  femoral  head  i-csults  iu  shortening  of  tlie  liiiili 
of  the  affected  side  though  the  i)Ositioii  assumed  is  not  necessarily 
characteristic  of  dorsal  dislocation  of  the  hip.  Slight  manipulation 
of  the  thigh  with  traction  is  usually  sufficient  to  bring  the  head  of 
the  femiu"  back  into  place  though  the  deformity  recurs  either  innne- 
diately  or  within  a  few  hours  following  reduction.  It  differs  from 
dislocation  of  the  hip  in  the  ease  with  which  i-ciluction  is  accom- 
plished and  the  tendency  to  recurrence  of  deformity.  The  condition 
however  closely  resend)les  fracture  of  the  neck  of  the  femur,  having 
frequently  been  mistaken  for  it. 

In  fracture  of  the  neck  of  the  femur  the  arc  described  by  the 
trochanter  when  the  thigh  is  rotated  is  of  shorter  radius  than  normal. 
In  fracture  of  the  rim  of  the  acetabulum  this  arc  is  normal  as  may 
be  demonstrated  by  comparison  with  the  opposite  side.  This  differ- 
ence, however,  is  often  slight  and  difficult  to  determine,  so  that  the 
use  of  the  X-ray  will  frequently  be  necessary  to  determine  the 
pathology  of  the  case.  The  fragment  usually  follows  the  head  when 
the  latter  is  returned  to  the  acetabulum,  and  crepitus  Avill  be  pro- 
duced as  the  fractured  surfaces  pass  each  other.  This  crepitus  may 
be  as  pronounced  as  in  fracture  of  the  hip,  or  it  may  be  exceedingly 
indistinct  according  to  the  position  of  the  fragment. 

3.  Fracture  of  the  tuberosity  of  the  ischium  is  an  exceedingly 
rare  condition  being  the  result  of  severe  localized  trauma.  The 
condition  is  therefore  likely  to  be  accompanied  by  wounds  of  the 
soft  parts  which  may  reach  to  the  bone,  rendering  the  fracture  com- 
pound. Abnormal  mobility  and  crepitus  may  be  elicited  by  palpa- 
tion through  the  rectum  or  vagina,  while  the  opposite  hand  gives 
counter-pressure  through  the  gluteal  muscles.  Local  pain,  tender- 
ness, etc.,  will  be  present. 

4.  The  coccyx  may  he  fractured  or  (Tislocatcd  by  direct  violence 
acting  either  from  without  or  within.  It  most  often  follows  falls 
on  the  buttocks  and  may  be  displaced  forward,  laterally  or  back- 
ward, the  latter  being  the  result  of  forces  acting  from  within  the 
pelvis,  such  as  the  descending  head  of  the  child.  The  distinction 
between  fracture  and  dislocation  of  this  bone  has  been  the  subject  of 
much  discussion  between  certain  writers,  but  for  practically  clinical 
];ui'poses  it  matters  little  since  the  symptoms  and  treatment  are 
identical.     ^Piu'  pain  in  fracture  or  dislocation  of  the  coccyx  may  be 


P^RAGTURES    AND    DTSTjOCATIONS    OK    I'ELVIS  501 

surprisingly  severe  considering  the  actual  damage  done.  Before 
reduction  is  accomplished  the  patient  usually  presents  the  symptoms 
of  agonizing  pain  which  radiates  up  the  back  and  down  the  dorsal 
aspect  of  the  thighs  from  the  seat  of  injury.  Even  after  the  suffer- 
ing has  been  relieved  by  correcting  the  displacement  it  will  be  many 
days  before  the  patient  can  move  about  with  any  degree  of  comfort. 
The  fracture  may  take  place  through  the  lower  end  of  the  sacrum  so 


Fig.  567. — Lateral  dislocation  of  the  coccyx.  The  arrows  point  to  the  coccyx 
which  has  been  outlined  to  accentuate  its  position.  The  lower  arrow  passes  through 
the  symphysis  pubis. 

that  a  portion  of  this  bone  is  displaced  with  the  coccyx.  The  higher 
the  fracture  in  the  sacrum  the  greater  the  likelihood  of  injury  to  the 
nerves  contained  within  the  sacral  canal  and  emerging  through  the 
sacral  foramina.  Injury  to  these  nerves  may  produce  pain,  numb- 
ness, loss  of  function,  etc.,  throughout  the  region  of  their  distribu- 
tion, and  in  severe  cases  to  trophic  disturbances  with  sores  or  sloughs 
in  the  skin  covering  the  coccyx  and  lower  end  of  the  sacrum.  The 
coccyx  and  sacrum  become  one  bone  in  the  aged  so  that  fracture  of 


502  FRACTURES   AND   DISLOCATIONS 

the  tip  of  the  sacrum  is  more  likely  to  occur  after  tlie  articuhition 
has  been  obliterated. 

The  usual  displacement  of  the  coccyx  is  angular  and  forward  so 
that  the  tip  of  the  bone  may  be  felt  pointing  forward  when  the 
examining  linger  is  introduced  into  the  rectum.  This  displacement 
encroaches  upon  the  cavity  of  the  rectum,  rendering  bowel  move- 
ments extremely  i)ainful.  The  lateral  and  posterior  dis()lacetnents, 
which  are  extremely  rare,  do  not  tend  to  recur  following  reduction; 
the  anterior  displacement  however  does  tend  to  recur  as  a  result 
of  the  action  of  tlie  attached  nuiscles.  Lateral  displacements  may 
be  palpated  tlirough  the  rectum;  posterior  displacements  will  be 
accompanied  by  an  abnormal  prominence  in  the  lower  part  of  the 
gluteal  cleft. 

The  symptoms  occurring  in  complicated  fracture  of  the  pelvis 
M'ill  depend  on  the  region  of  the  pelvis  injured,  together  with  the 
nature  and  extent  of  the  injury  sustained  by  the  soft  parts  in  the 
region  of  the  fracture.  When  any  portion  of  the  pelvic  girdle  is 
fractured  numerous  complications  may  exist  so  that  it  will  be  best 
to  consider  the  bone  injuries  first  in  the  order  previously  set  down, 
after  which  the  complications  will  be  taken  up. 

The  mechanism  and  pathology  of  fracture  of  the  pelvic  girdle 
are  of  secondary  importance  when  compared  to  the  complications 
commonly  found  accompanying  this  condition. 

1.  Separation  of  the  symphysis  pubis  may  be  the  result  of 
indirect  violence  forcing  the  ossa  innominata  apart,  due  to  the 
overaction  of  the  adductor  group  of  muscles  while  the  thighs  are 
in  abduction,  or  to  the  spreading  action  of  the  foetus  as  it  descends 
through  the  parturient  canal.  The  separation  of  the  pubes  may 
be  felt  and  in  many  instances  seen.  Separation  of  over  one  and  a 
half  inches  is,  as  a  rule,  accompanied  by  rupture  of  the  anterior 
sacro-iliac  ligaments  or  fracture  in  some  other  portion  of  the 
pelvic  ring. 

With  separation  of  the  symphysis  the  patient  suffers  considerable 
pain  and  the  weight  bearing  function  of  the  pelvis  is  interfered 
with  as  a  result  of  the  dissolution  of  the  counter-arches.  Rupture 
of  the  ligaments  and  loosening  of  one  of  the  sacro-iliac  joints  will 
allow  one  os  innominatum  to  be  displaced,  usuall}^  upward. 
Symphyseal  separation  may  be  associated  with  fracture  of  the 
pelvis  or  with  loosening  of  one  or  both  sacro-iliac  joints.  One 
pubic  bone  may  be  displaced  behind  the  other  and  when  such  is 


FRACTURES   AND   DISLOCATIONS   OF    PELVIS  503 

the  case  it  is  usually  very  difficult  to  reduce  the  deformity.  The 
common  complication  is  rupture  of  the  urethra  or  bladder,  the 
symptoms  of  which  will  be  described  later. 

2.  Fracture  of  the  anterior  portion  of  the  pelvic  ring  occurs 
more  frequently  than  any  of  the  other  fractures  in  this  group. 
The  details  of  the  lines  of  fractures  vary  greatly.  Both  rami  of  the 
pubis  are  usually  fractured,  the  upper  one  anterior  to  the  ilio- 
pectineal  eminence  and  the  lower  near  the  junction  of  the  descend- 
ing pubic  with  the  ischial  ramus.  The  condition  is  not  infre- 
quently bilateral.  Deformity  is  usually  present  and  can  be  de- 
tected by  palpation.  The  condition  may  be  the  result  of  violence 
applied  to  the  pelvis  in  the  antero-posterior  direction  or  it  may  be 
due  to  lateral  squeezing.  Fractures  in  the  lateral  or  posterior 
portions  of  the  pelvic  ring  are  common  as  complications,  and  are 
seen  in  instances  in  which  the  causative  trauma  continues  to  act 
after  the  anterior  portion  has  been  fractured.  The  patient  is 
unable  to  walk,  pain  is  severe,  and  shock  often  pronounced, 
especially  in  the  presence  of  visceral  complications.  Rupture  of 
the  bladder  and  injury  to  the  urethra  are  common  as  complica- 
tions (see  page  509). 

3.  Fracture  of  the  lateral  portions  of  the  pelvis  in  the  region  of 
the  acetabulum  occurs  in  conjunction  with  fracture  of  the  anterior 
portion  of  the  ring  as  previously  explained,  and  also  as  a  result  of 
trauma  transmitted  through  the  head  and  neck  of  the  femur.  The 
first  named  type  of  fracture  is  more  or  less  vertical,  passing  from 
the  crest  of  the  ilium  to  the  great  sacro-sciatic  foramen.  The  line 
of  fracture  frequently  branches  in  its  upper  end.  It  may  pass 
into  or  cross  the  sacro-iliac  joint  involving  the  sacrum:  in  other 
instances  it  comes  out  below  the  anterior  inferior  iliac  spine. 
When  it  crosses  the  sacro-iliac  joint  it  may  follow  more  or  less 
closely  the  line  of  the  articulation,  or  it  may  follow  the  sacral  foram- 
ina separating  the  lateral  mass  of  the  sacrum  from  the  rest  of 
the  bone.  The  directions  which  the  lines  of  fracture  may  take  in 
the  lateral  portions  of  the  pelvis  are  very  variable  and  accordingly 
two  cases  will  seldom  show  the  same  deformity.  The  fact  that  the 
femur  articulates  with  this  portion  of  the  pelvis  often  gives  rise 
to  symptoms  of  importance.  The  lower  extremity  of  the  affected 
side  usually  lies  helpless  and  is  shorter  than  normal  because  of  the 
displacement  of  the  acetabulum.  The  muscles  of  the  thigh  are  in 
spasm  and  any  attempt  at  passive  motion  is  seriously  objected  to 


504  FRAPTT'RER    AXD    DTi^T-OfATTOXS 

hy  the  patient.  Abnormal  mobility  aiul  creijitus  can.  as  a  nib\  be 
elicited  with  ease  by  direct  palpation  or  manipulation  ol"  Ihc  tbiiili, 
and  the  pelvic  deformity  is  often  plainly  visible.  Injury  1o  tlie 
acetabulum  and  adjoining  pelvis  resulting  from  trauma  transmitted 
through  the  femur  is  rare,  because  wtieu  violence  is  applied  to  the 
trochanter  the  neck  of  the  femur  is  iiuk-Ii  moi-c  liable  to  fracture 
than  is  the  pelvis.  The  condition,  however,  does  occasionally  occur 
anil  a  variety  of  fractures  may  result  when  the  pelvis  is  injured 
in  this  manner:  the  acetabulum  may  be  "bi-oken  out,"  so  to  speak, 
of  the  rest  of  the  pelvis  with  three  lines  of  fracture,  one  from  a 
point  below  the  antero-infei-ior  spine  to  the  great  sacro-sciatic 
notch,  the  second  across  the  ascending  ramus  of  the  pubis  and  the 
third  across  the  body  of  the  ischium  below  the  acetabulum ; 
another  result  is  that  the  violence  applied  to  the  acetabulum  pro- 
duces radiating  fractures  which,  following  the  lines  of  least  resist- 
ance, reach  the  sacro-sciatic  notch,  thyroid  foramen  and  rim  of  the 
pelvis;  in  addition  w^e  may  have  injury  of  the  bone  at  the  bottom 
of  the  acetabular  cavity  without  fracture  of  adjoining  portions  of 
the  pelvis.  A  rare  condition  is  sometimes  seen  in  which  the  head  of 
the  femur  is  driven  through  the  bottom  of  the  acetabulum  into  the 
pelvic  cavity.  The  symptoms  of  deformity  and  disturbance  in 
function  will  vary  with  the  pathology  of  the  condition.  When  the 
acetabulum  is  fractured  there  is  likely  to  be  shortening  of  the 
lower  extremity,  abnormal  mobility  of  the  upper  end  of  the  femur 
and  crepitus  wdien  the  thigh  is  manipulated.  When  the  head  of 
the  fenuir  is  driven  through  the  acetabulum  there  will  be  abnormal 
fixation  of  the  upper  end  of  the  femur,  mesial  displacement  of  the 
troclianter  as  palpated  externally,  and  the  patient  will  be  able  to 
bear  the  weight  of  the  body  on  the  limb  of  the  affected  side  since 
the  ring  of  the  pelvis  is  not  fractured  and  the  weight  is  trans- 
mitted to  the  neck  of  the  femur  instead  of  to  the  head.  The  shock 
and  pain,  however,  will  usually  be  sufficient  to  prevent  the  patient 
attempting  anything  in  the  way  of  walking.  Fracture  of  the 
pelvis  by  lateral  compression  is  usually  preceded  by  fi-acture  of 
the  "tie  arches"  composing  the  anterior  part  of  the  ring,  so  that 
the  symptoms  of  fracture  of  both  these  portions  of  the  pelvis  will 
be  present  at  the  same  time. 

4.  Separation  of  the  sacro-iliac  synchondrosis,  as  an  isolated 
injury,  is  an  extremely  rare  condition.  Tt  occurs  sometimes  in 
conjunction    with    fractui-e   of   tlie   antei-ioi-   poi-tion   of   the   pelvic 


FRACTIIKKtt    AND    DTSr.OOATTONS    OF    1'ET.VTS  505 

ring  or  separation  of  the-  symphysis  pubis.  Inward  displacement 
of  the  lateral  portions  of  the  pelvis,  such  as  occurs  in  transverse 
crushes,  may  result  in  rupture  of  the  posterior  ligaments  behind 
the  articular  surfaces.  Spreading  of  the  pelvis  throws  the  strain 
on  the  anterior  sacro-iliac  ligaments,  which  rupture,  allowing  the 
anterior  aspect  of  the  joint  to  gape.  The  strength  of  these  liga- 
ments, however,  is  so  great  that  fracture  in  the  adjoining  bone  is 
more  frequently  produced  than  rupture  of  the  ligament  itself. 
Displacement  in  one  or  both  sacro-iliac  joints,  or  separation  of  all 
three  pelvic  articulations  is  known  to  have  taken  place,  but  such 
conditions  are  very  rare.  Laxity  or  rupture  of  the  ligaments  of 
the  sacro-iliac  joints  will  allow  an  upward  and  outward  displace- 
ment of  the  ilium  if  the  patient  attempts  to  sit  or  stand.  Disturb- 
ances in  function  following  injury  to  the  pelvic  articulations  will 
give  rise  to  symptoms  similar  to  those  occurring  in  fracture  of  the 
same  region.  The  sacro-iliac  joints  are  not  infrequently  subject 
to  sprains  in  falls  and  blows  on  the  pelvis,  and  although  the  con- 
dition is  by  no  means  a  dislocation,  it  deserves  mention.  There  is 
more  or  less  pain  in  the  joint  when  the  patient  moves  about,  and 
pressure  on  the  anterior  superior  spines  produces  pain  in  the  region 
of  the  injury.  The  condition  is  usually  not  serious,  being  followed 
by  prompt  recovery  with  rest  in  bed  for  a  few  days. 

5.  Transverse  fracture  of  the  sacrum  is  the  result  of  severe  local- 
ized trauma  and  is  fortunately  a  rare  condition.  A  small  portion 
of  the  sacrum  may  be  displaced  with  the  coccyx  but  this  condition 
is  described  under  fracture  of  the  coccyx.  The  fragment  in  trans- 
verse fracture  of  the  sacrum  is  usually  displaced  forward,  project- 
ing into  the  cavity  of  the  pelvis  and  is  commonly  accompanied  by 
injury  to  the  rectum  and  the  nerves  contained  within  the  sacral 
canal.  The  displacement  is  easily  detected  by  palpation.  Severe 
pain,  radiating  up  the  back  and  down  the  thighs,  may  be  present. 
Shock  is  often  pronounced.  Paralysis  of  the  bladder  and  rectum, 
due  to  injury  of  the  nerves  supplying  these  structures  as  they  pass 
through  the  sacrum,  is  not  uncommon.  Paralysis  of  the  lower  leg 
type  has  been  noted  in  some  cases.  The  displacement  is  produced 
by  the  original  trauma  and  the  action  of  the  attached  muscles. 
The  deformity  usually  recurs  promptly  following  reduction. 

Diagnosis. — When  fracture  of  the  pelvis  is  suspected  the  exam- 
ination should  be  conducted  systematically  in  order  that  the  full 
extent  of  the  injury  may  be  recognized.     Moreover  the  examination 


506  FRACTURES   AND    DISLOCATIONS 

sliould  not  be  considered  complete  as  soon  as  we  find  one  line  of 
fracture,  since  multiple  fracture  and  visceral  complications  are 
common.  The  patient  should  be  placed  in  a  position  wliich  is 
accessible  and  convenient  for  the  surgeon,  preferably  an  operating 
table,  and  unless  there  are  special  contraindications  it  is  advisable 
to  administer  a  short  anesthetic.  The  pelvic  girdle  is  covered  with 
a  number  of  muscles  and  many  of  its  parts  are  deeply  situated,  yet 
by  proper  palpation  fracture  and  articular  displacements  can,  as  a 
rule,  be  determined  without  difficulty.  liy  insi)eetion  alone  it  is 
often  possible  to  detect  asymmetry  of  the  two  si(h's  of  the  pelvis, 
raising  of  one  of  the  ossa  innoniinata,  or  the  median  depression  of 
symphyseal  separation.  The  shortening  and  helphss  attituch'  in 
which  the  lower  extremity  may  lie  is  indicative  of  fracture  of  tlie 
femur  or  pelvis.  Palpation  will  usually  elicit  crepitus  and  ab- 
normal mobility  in  the  presence  of  fracture  or  separation.  With 
the  patient  in  the  dorsal  position  and  the  pelvis  solidly  supported, 
backward  pressure  is  made  Avith  the  palms  of  the  hands  on  the 
antero-superior  iliac  spines,  then  the  iliac  crests  are  crowded 
together  and  finally  antero-posterior  pressure  is  exerted  with  one 
hand  over  the  symphysis  and  the  other  on  the  sacrum.  Pressure 
in  these  directions  will  usually  elicit  mobility  and  crepitus  if  the 
fracture  has  passed  through  the  pelvic  girdle.  Due  care  should 
be  exercised  to  avoid  further  injury  to  the  viscera  in  manipulating 
the  parts  since  the  examination  may  thus  infiiet  more  serious 
injury.  The  pubes  and  their  ascending  rami  are  near  the  surface 
and  their  outline  may  be  followed  throughout.  The  mesial  borders 
of  the  ischio-pubic  rami  may  be  palpated  at  the  lateral  boundaries 
ff  the  perineum  with  the  thighs  abducted.  The  anterior  superior 
iliac  spines  are  subcutaneous  and  the  iliac  crests  may  be  palpated 
throughout  their  extent,  terminating  posteriorly  in  the  postero- 
superior  iliac  spines.  The  tuberosity  of  the  ischium  may  be 
palpated  with  the  fingertips  of  one  hand  resting  in  the  lower  part 
of  the  gluteal  cleft  while  the  opposite  hand  makes  counter-pressure 
through  the  buttock.  It  may  also  be  palpated  through  the  rectum 
or  vagina.  The  spines  of  the  sacrum  may  be  palpated  throughout 
but  the  remainder  of  the  posterior  surface  of  the  bone  is  obscured 
to  touch  by  the  heavy  fascia  covering  the  lower  end  of  the  erector 
spinie  mass.  If  the  finger  be  passed  into  the  rectum  and  the  thumb 
opposed  posteriorly  the  coccyx  may  be  thoroughly  palpated,  and 
the  presence  of  abnormal  mobility  and  crepitus  determined  when 


PRACTURK8    AND    DISLOCATIONS    OF    PEFyVIS  507 

present.  The  presence  of  fracture  is,  as  a  rule,  easily  reco^ized 
by  palpation  as  above  described,  but  it  is  often  impossible  to  deter- 
mine the  details  without  enii)loyrng  the  X-ray. 

Treatment. — The  treatment  of  fracture  of  the  pelvis  aside  from 
the  complications  is  usually  a  simple  matter.  If  the  deformity  is 
not  great  immobilization  and  rest  in  bed  will  be  all  that  is  required. 
In  fracture  of  the  crest  of  tli.e  ilium  a  body  swathe  may  be  used  or 
adhesive  straps  may  be  employed  to  steady  the  fragment.  Too 
much  pressure  should  be  avoided,  as  it  may  displace  the  fragment 
inward,  thus  increasing  the  deformity.  Rest  in  bed  is  necessary 
and  the  patient  should  be  warned  against  undue  use  of  the 
abdominal  muscles.  The  bowels  should  be  kept  soft  to  avoid 
straining  at  stool.  Moderate  deformity  does  not  mean  impairment 
of  function  and  seldom  requires  special  measures  for  its  correction. 
A  flattened  hip  in  a  young  woman,  however,  is  often  considered  a 
serious  matter  and  we  may  be  called  upon  to  secure  the  fragment 
by  operation  for  the  correction  of  deformity.  Fracture  of  the  rim 
of  the  acetabulum  is  to  be  treated  similarly  to  fracture  of  the  hip 
and  will  be  considered  with  the  treatment  of  fractures  of  the  upper 
end  of  the  femur.  Fracture  of  the  tuberosity  of  the  ischium  rarely 
shows  great  displacement  and  recovery  with  moderate  deformity  is 
followed  by  good  function.  Rest  in  bed  and  a  pneumatic  ring  to 
relieve  the  region  of  fracture  from  pressure  will  constitute  the 
essentials  of  treatment.  If  the  tuberosity,  however,  shows  enough 
inward  displacement  to  encroach  on  the  transverse  diameter  of  the 
birth  canal  in  a  woman  of  the  child-bearing  period,  it  is  best  to  cut 
down  on  the  fragment  before  union  commences  and  secure  it  in 
place  with  wire  or  some  other  form  of  suture  material.  Fracture 
or  dislocation  of  the  coccyx  calls  for  immediate  reduction  to  relieve 
the  suffering  and  if  necessary  opiates  should  be  used  in  addition. 
All  of  the  displacements  except  the  anterior  show  little  or  no  tend- 
ency to  recurrence  and  not  much  in  the  way  of  treatment  will  be 
required  aside  from  reduction  and  relief  of  pain.  The  patient 
should  be  kept  in  bed  for  a  week  or  so  or  until  the  extreme  tender- 
ness has  subsided.  During  this  time  the  use  of  a  pneumatic  ring 
will  add  greatly  to  the  patient's  comfort.  In  fracture  or  disloca- 
tion with  anterior  displacement  it  is  difficult  to  keep  the  fragment 
in  reduction,  because  of  the  muscles  attached  to  the  coccyx.  The 
condition  has  been  treated  by  packing  the  rectum  and  the  exhibition 
of  opiates  to  produce  constipation.     If  a  large  rubber  tube,  rolled  in 


508  FRACTURKS    AXI>    niSI.OCATIONS 

gauze,  is  introduced  it  will  allow  the  escape  of  flatus  and  li(|iii(l 
feces  witliout  removing  the  dressing.  AVhen  this  dressing  is  used 
the  bowels  slioukl  l)e  kept  liquid  by  laxatives.  In  any  case  the 
rectal  packing  will  liavf  to  be  mainlaiiicd  until  the  callus  is  suf- 
ficiently firm  to  i)revent  the  recuri-ence  of  deforniily.  It  should 
be  renewed  often  enough  during  the  after-treatment  to  keep  the 
parts  clean  and  avoid  rectal  irritation.  Vaseline  facilitates  intro- 
duction and  is  less  irritating  to  the  mueosa  than  plain  gauze.  If 
these  measures  do  not  eontrol  the  tendency  toward  displacement  or 
])ain  following  the  injury  persists  and  defecation  is  i)ainful  because 
of  tile  anterior  displacement,  excision  of  the  coccyx  is  indicated  and 
will  be  followed  bv  relief  and  no  disturbance  in  function. 


ii_.  .')i;>.  —  I'hi^iHi-  ...1  L'nris  fliuiWe  spica  of  trunk  and  both  thighs  for  the  treat- 
ment ol'  fracture  of  the  pelvis.  The  thighs  should  be  slightly  flexed  and  abducted  to 
allow  proper  care  of  the  patient  and  use  of  the  bed  pan. 

In  the  above  isolated  fractures  of  the  pelvis  the  patient  may  be 
made  comparatively  comfortable  by  rest  in  bed  and  proper  nursing, 
but  when  the  ring  of  the  pelvis  is  fractured  the  condition  is  much 
more  serious  and  difficult  to  treat.  The  element  of  importance  in 
separation  of  the  symphysis,  fracture  of  the  puhic  and  ischio-puhic 
rami,  lateral  fracture  of  the  pelvis  and  separation  of  the  sacro-iliac 
joints  is  the  breaking  of  the  pelvic  girdle  and  the  likelihood  of 
visceral  compljcations.  The  indications,  therefore,  in  the  treatment 
of  these  conditions  will  be  to  secure  immobilization  of  the  pelvic  ring 
and  provide  for  the  complications  as  soon  as  they  are  recognized. 
The  various  visceral  complications  are  not  peculiar  to  any  one  form 
of  fracture  of  the  pelvic  ring  and  because  of  this  fact  they  will  be 
considered  under  a  separate  heading  (see  page  509).     A  Bradford 


FRACTURES   AND   DISLOCATIONS   OF    PELVIS  509 

bed-frame  or  some  substitute  is  essential  to  prevent  disturbing  the 
fragments  whenever  the  bed-pan  is  used  and  to  keep  the  bed  and 
patient  properly  clean.  In  place  of  the  Bradford  bed-frame  we  may 
employ  a  double  plaster  of  Paris  spica  extending  from  the  waist  to 
the  knees,  and  in  this  manner  the  pelvis  is  secured  so  that  the  patient 
may  be  rolled  from  side  to  side,  the  bed-pan  used  and  the  clothes 
changed  without  disturbing  the  parts  or  increasing  the  suffering. 
The  cast  should  be  applied  with  the  thighs  slightly  abducted  and 
with  moderate  flexion  at  the  knees  and  hips,  thus  giving  ready  access 
to  the  anal  region  and  the  genitals,  besides  securing  a  more  com- 
fortable position  for  the  patient.  Traction  on  the  thigh  may  reduce 
deformity  when  the  portion  of  the  ring  to  which  the  femur  is 
attached  is  driven  in.  By  manipulation  it  is  sometimes  possible  to 
correct  some  of  the  displacements.  The  treatment  of  fracture  of 
the  pelvic  girdle  consists  mainly  in  the  treatment  of  the  complica- 
tions which  accompany  the  condition. 

Complications. — Complications  very  rarely  occur  except  in  cases 
in  which  the  pelvic  girdle  is  fractured,  but  their  presence  in  isolated 
fracture  of  some  of  the  bones  of  the  pelvis  or  even  in  cases  of 
abdominal  or  perineal  trauma  without  fracture  should  not  be  lost 
sight  of.  The  visceral  injuries  accompanying  fracture  of  the 
pelvic  girdle  are  far  more  important  than  the  fracture  itself,  being 
responsible  for  the  high  mortality  following  this  fracture.  Rupture 
of  the  urethra,  rupture  of  the  bladder,  rupture  of  the  bowel,  injury 
to  vessels  (especially  the  external  iliacs)  and  injury  to  nerves 
(especially  the  sacral  and  coccygeal)  are  among  the  complications 
most  common  in  fracture  of  the  pelvis.  Renal  injury  sometimes 
occurs  as  an  associated  condition. 

The  symptoms  of  rupture  of  the  urethra  will  depend  on  the  region 
of  the  canal  injured.  Injury  is  most  frequently  sustained  in  the 
membranous  portion,  as  the  canal  emerges  from  the  superficial 
layer  of  the  triangular  ligament.  If  the  tear  in  the  urethra  is 
outside  the  cut-off  muscle  the  hemorrhage  from  the  meatus  will  be 
more  or  less  continuous.  There  is  often  a  dribbling  of  blood  for 
some  time  following  the  accident,  which  grows  less  and  finally  stops 
only  to  begin  again  when  urine  is  passed  or  micturition  attempted. 
Pain  and  tenesmus  are  usually  pronounced.  Swelling  of  sudden 
onset,  due  to  urinary  accumulation,  is  seen  in  the  perineum  and  if 
not  relieved  soon  extensively  infiltrates  the  surrounding  tissues. 
The  catheter  usually  meets  obstruction  when  it  encounters  the  site  of 


510  FRACTURES   AND   DISLOCATIONS 

rupture.  If  the  floor  of  the  urethra  is  torn  catheterization  may 
sometimes  he  accomplished  ])y  following  the  roof  with  a  metal  instru- 
ment. Complete  tear  almost  always  ivcjuires  operative  inlci-vention 
to  enter  the  hladder.  If  tlie  rupture  is  behind  the  cut-off  muscle  the 
blood  will  flow  back  into  the  bladder,  appearing  at  the  meatus  only 
with  micturition.  If  the  rupture  is  complete,  retention  is  the  rule 
with  occasional  dribbling  of  bloody  urine.  "When  retention  is 
present  the  symptoms  of  distended  bladder  will  supervene  wdthin  a 
few  hours.  The  diagnosis  of  rupture  of  the  urethra  is  made  on  the 
s.ymptoms  enumerated  aliove.  In  some  instances  the  tear  in  the 
u)'('tlira  nuiy  be  inspected  by  means  of  the  urethrascope  or  posterior 
endoscope  or  l)etter  still  the  cystourethrascope. 

Treatment  of  riipfKre  of  the  urethra. — In  rui)ture  of  tlic  urethra 
the  prime  indication  is  for  prompt,  continuous  and  complete  drain- 
age of  the  bladder.  Cases  in  which  the  passage  of  the  catheter  has 
been  possible  have  been  successfully  treated  by  means  of  continuous 
catheterization  and  suction  apparatus.  By  far  the  safest  method 
however  consists  in  prompt  external  urethrotomy  followed  by 
direct  drainage  of  the  bladder  through  a  rectal  tube  in  the  perineum 
connected  by  means  of  rubber  tubing  with  a  bottle  beneath  the 
bed.  Perineal  drainage  instituted  early  will  accomplish  more  in 
preventing  urinary  infiltration  than  anything  else.  When  the  tear 
is  complete  the  roof  of  the  urethra  should  be  brought  together  and 
secured  by  suture  during  the  operation.  The  most  satisfactory 
catheter  in  these  cases  is  the  rectal  tube.  In  some  instances  consid- 
erable difficulty  is  experienced  in  finding  the  proximal  end  of  the 
torn  urethra  and  in  such  cases  it  is  better  to  enter  the  bladder  supra- 
pubically  and  do  a  retrograde  catheterization  rather  than  to  pro- 
long the  search  in  the  perineum  with  the  patient  already  suffering 
considerable  shock  from  the  accident.  During  the  treatment  of 
this  condition  it  is  always  advisable  to  determine  the  condition  of 
the  bladder  to  avoid  overlooking  complications  of  this  viscus. 

Symptoms  of  rupture  of  the  hladder. — Shock  is  always  a  prom- 
inent symptom  aside  from  the  shock  occurring  in  fracture  of  the 
pelvis.  Pain  is  pronounced  and  tenderness  present.  If  the  rupture 
is  extraperitoneal  the  patient  passes  bloody  urine  which  is  not  pre- 
ceded by  blood  as  in  urethral  injury.  Suprapubic  swelling  due  to 
infiltration  of  urine  into  the  space  of  Retzius  makes  its  appearance 
a  few  hours  following  the  injury.  When  the  rupture  is  intra- 
peritoneal the  urine  passes  from  the  bladder  into  the  peritoneal 


FRACTURES   AND    DISLOCATIONS   OF    PELVIS  511 

cavity  and  accordingly  the  viscus  does  not  become  distended.  If 
sufficient  nrine  collects  in  the  abdominal  cavity,  dullness  on  percus- 
sion may  be  noted  in  the  flanks.  The  patient  is  unable  to  pass  urine 
although  tenesmus  is  present  and  frecjuent  ])aiiifiil  altempts  at 
micturition  are  made. 

Diagnosis  of  rupture  of  the  Madder  will  be  followed  by  the 
symptoms  peculiar  to  this  injury  as  described  above.  In  addi- 
tion we  may  test  the  walls  of  the  bladder  by  introducing  a 
measured  quantity  of  sterile  salt  solution  through  a  catheter  and 
remeasuring  it  after  it  has  been  withdrawn.  If  the  bladder  has 
been  ruptured  intraperitoneally  it  will  be  impossible  to  fill  the 
viscus,  and  the  fluid  when  withdrawn  will  be  much  less  than  the 
quantity  introduced.  When  the  rupture  is  extraperitoneal  the  loss 
of  fluid  will  often  be  too  small  to  detect.  The  catheter  should  not 
be  introduced  further  than  is  necessary  to  reach  the  bladder  since 
in  some  cases  of  intraperitoneal  rupture  it  may  pass  through  the 
rent  in  the  bladder  into  the  peritoneal  cavity,  thus  evacuating  urine 
which  has  escaped  from  the  bladder  or  salt  solution  which  has 
been  introduced  for  diagnostic  purposes.  This  method  is  not  ideal 
and  has  been  condemned  by  some  genito-urinary  surgeons,  yet  it 
is  the  best  we  have  and  nothing  is  more  fatal  to  the  patient  than 
the  expectant  plan  of  treatment  followed  because  of  ignorance  of 
the  conditions  present.  The  questionable  damage  done  by  the 
passage  of  salt  solution  (previously  sterilized)  from  the  ruptured 
bladder  into  the  abdominal  cavity  and  followed  by  operation  is 
more  than  outweighed  by  the  benefit  the  patient  derives  from  a 
positive  diagnosis  and  prompt  surgical  treatment.  The  cystoscope 
is  valueless  in  intraperitoneal  rupture  since  the  bladder  cannot  be 
distended.  When  the  rupture  is  extraperitoneal  it  will  sometimes 
be  possible  to  inspect  the  injury  by  means  of  this  instrument  in 
competent  hands.  The  hemorrhage,  however,  is  usually  sufficient 
to  obscure  the  water  with  which  the  bladder  is  distended,  so  rapidly 
that  vision  is  rendered  unsatisfactory  or  impossible. 

Treatment  of  rupture  of  the  bladder. — Rupture  of  the  bladder 
calls  for  immediate  operative  intervention  if  we  expect  to  save 
the  patient.  In  the  intraperitoneal  form  of  rupture  the  rent  must 
be  closed  through  an  abdominal  incision  and  the  bladder  drained 
from  below  through  a  permanent  perineal  tube  to  prevent  disten- 
tion of  the  viscus  and  tension  on  the  sutures.  In  extraperitoneal 
rupture  the  tear  is  frequently  situated  in  the  lower  anterior  aspect 


512  FRACTURES   AND   DISLOCATIONS 

of  the  bladder  or  the  region  of  the  trigone,  and  should  be  repaired 
with  fine  absorbable  suture  material.  The  situation,  however,  of 
these  extraperitoneal  tears  is  inaccessible  and  difficult  to  oi)erate 
upon  and  the  condition  of  shock  in  whicli  we  find  the  patient  often 
precludes  any  prolonged  operation-  or  anesthetic.  It  is  therefore 
best  in  many  cases  of  extraperitoneal  tear  to  establish  free  perineal 
drainage  at  once,  leaving  the  rent  to  take  care  of  itself. 


PART  III. 
LOWER  EXTREMITY. 


CHAPTER  XXXVI. 

DISLOCATIONS  OF  THE  HIP. 

Surgical  Anatomy. — The  hip-joint  is  a  typical  ball-and-socket 
articulation,  and  the  depth  of  the  acetabulum  is  such  tliat  the 
integrity  of  the  joint  is  much  less  dependent  upon  the  ligaments 
than  is  the  case  in  the  shoulder-joint.  Numerous  muscles  are  at- 
tached to  the  upper  end  of  the  femur  and  the  great  trochanter, 
all  of  which  exert  more  or  less  of  an  upward  or  inward  pull,  their 
action  being  much  more  apparent  in  fracture  of  the  neck  of  the 
femur  than  in  dislocations  of  the  hip.  The  muscle  of  greatest  im- 
portance in  this  region  is  the  obturator  internus  which  is  inserted 
into  the  digital  fossa  after  having  emerged  from  the  pelvic  cavity 
through  the  lesser  sacro-sciatic  notch.  If  the  head  of  the  bone 
passes  under  this  tendon  we  have  the  sciatic  form  of  dislocation. 
When  it  passes  over  the  muscle  we  have  the  iliac  type  in  which  the 
head  of  the  bone  rests  on  the  dorsum  ilii.  The  hip  has  five  liga- 
ments: ligamentum  teres,  the  capsule,  the  cotyloid,  transverse,  and 
ilio-femoral.  The  ligamentum  teres  passes  from  the  ovoid  depres- 
sion on  the  head  of  the  femur  to  the  margins  of  the  fossa  acetabuli. 
The  capsular  ligament  surrounds  the  joint,  is  attached  at  its  inner 
end  to  the  margins  of  the  acetabulum,  while  the  opposite  end  is 
attached  to  the  femoral  neck.  The  anterior  portion  of  the  capsule 
extends  downward  and  outward  as  far  as  the  spiral  line  of  the 
femur,  while  the  posterior  portion  of  this  ligament  reaches  to 
within  a  half  inch  of  the  posterior  intertrochanteric  line.  The 
capsule  is  lined  with  synovial  membrane  and  possesses  a  number 
of  accessory  thickenings  along  the  lines  of  the  greatest  and  most 
frequent  strains.  The  upper  and  anterior  portion  of  this  tube- 
like ligament  is  the  heaviest.  The  posterior  inferior  portion  is 
comparatively  thin,  loose  and  lax.  The  cotyloid  ligament  is  an 
intracapsular  fibro-cartilaginous  ring  attached  to  the  margins  of 
the  acetabulum;  it  serves  to  deepen  the  cavity  and  strengthen  the 
joint.  "Where  it  crosses  the  cotyloid  notch,  it  is  known  as  the 
transverse  ligament.     The   above  ligaments   are  all  more   or  less 

515 


516 


P^RACTIJRES   AND   DISLOCATIONS 


essential  factors  in  tlic  liip,  ])iit  the  ligament  of  by  far  the  greatest 
importance  is  the  ilio-fitnortil  or  Y-ligament  of  Bigclow.  This  con- 
sists of  an  accessory  thickening  in  the  anterior  portion  of  the  cap- 
sule. Its  lower  extri'inity  is  attached  lo  tlic  aiitei'ior  intertro- 
chanteric line,  while  its  ui){)er  end  is  attached,  with  the  straight 
head  of  the  rectus,  to  the  anterior  inferior  iliac  spine.  Tn  exten- 
sion of  tile  thigh  tills  ligament  is  tense,  and  Hiiiils  motion  at  the 
hip;   in   tlexion   it   is  i-elaxed.      in   a    jxM'son   of  average   liuild   it  is 


Figr.    569. — The  ilio-feiiioral   nr   Y-li(;aiiient   of   Bisrelow.   a    most    ini|)oitiUit   slriictui'e   in 
dislocations  of  the  hip. 


said  to  pos.sess  a  tensile  strength  of  two  hundred  and  fifty  pounds 
or  more,  and  thus  it  will  be  readily  understood  tiiat  this  ligament 
is  rarely  torn  in  dislocations  of  the  hip. 

The  head  of  the  femur  when  displaced  may  lie  anywhere  about 
tlie  acetabulum,  depending  on  the  manner  in  which  violence  was 
applied  at  the  tiiiu-  of  the  aceidtmt,  and  tlie  subsecjuent  action  of 
tlie  muscles  and  ligaments  attaclied  to  the  bone.  Although  the 
head  may  lie  in  almost  any  position  around  the  acetabular  ring, 
yet  it  almost  invariably  leaves  tlie  joint  tlii'ough  a  rent  in  the  lower 


DTRTiOOATIONR    OF    TITE   HIP  517 

portion  of  the  capsule.  After  escaping -from  the  socket  it  usually 
rides  upward  either  in  front  of,  or  behind  the  acetabulum.  Ac- 
cordingly numerous  classifications  have  been  given  of  dislocations 
of  the  hip,  all  of  them  based  on  the  position  occupied  by  the  dis- 
placed head.  There  are  two  main  groups  deserving  of  consider- 
ation, namely,  anterior  and  posterior.  The  resultant  attitude  as- 
sumed by  the  lower  extremity  is  purely  a  question  of  mechanics, 
depending  upon  the  relations  of  the  displaced  head  and  the  influ- 
ence of  the  Y-ligament.  Whatever  position  the  femoral  head  may 
find,  the  distance  between  the  anterior  inferior  spine  and  the  spiral 
line  cannot  exceed  the  length  of  the  ilio-femoral  ligament.     The 


Fig.  570. — Iliac  dislocation  of  the  hip.  The  higher  the  head  rests  on  the  ilium 
the  more  pronounced  will  be  the  inward  rotation  of  the  thigh  provided  the  Y-ligament 
is    not   ruptured. 

Fig.   571. — Sciatic  dislocation  of  the  hip.      The  head  rests   in  the  sciatic   notch. 

action  of  this  ligament,  under  these  conditions,  might  be  likened 
to  that  of  a  "toggle  joint"  or  "shackle,"  which,  though  movable 
at  one  end,  maintains  a  more  or  less  fixed  relation  between  the 
attached  objects.  If  the  head,  therefore,  is  displaced  outward  and 
backward,  the  knee  must  of  necessity  come  forward  and  inward, 
and  in  like  manner  the  other  characteristic  deformities  accom- 
panying the  various  dislocations  of  the  hip,  may  be  readily  under- 
stood if  one  appreciates  the  anatomy,  particularly  the  action  of 
the  ilio-femoral  ligament. 

A  second  element  in  the  production  of  deformity  is  the  angle 
at  which  the  femoral  neck  joins  the  shaft,   and  the   consequent 


518 


FRACTHHRS    AND    niSL(  )C.\'I'1()NS 


leverage  exerted  by  the  neck  when  the  head  of  the  bone  is  out  of 
the  socket.  Thus,  if  the  posterior  aspect  of  the  neck  lies  in  con- 
tact with  the-  OS  innoniinatuni,  as  in  the  anterior  displacements, 


Ilio-pectineal  dislocation  of  tlie  hip. 
Pubic  dislocation  of  the  hip. 


Fig. 


Fig.    574. — Obturator   or   thyroid   dislocation   of   the   hip. 

Fig.   575. — Perineal  dislocation;  an  e.xaggeration  of  the  obturator  type. 

outward  rotation  must  be  the  result;  when  the  reverse  condition 
is  true,  the  anterior  surface  of  the  neck  lying  in  contact  with  the 
hip  bone,  as  in  posterior  dislocations,  inward  rotation  of  the  thigh 
will  1)6  present.     The  depth  of  the  socket  and  the  heavy  ligaments 


DISLOCATIONS   OF   THE   HIP 


519 


surrounding  the  joint  account  for  the  extreme  rarity  of  disloca- 
tion of  this  articulation. 

If  the  antero-superior  iliac  s])ine  be  connected  by  a  line  with 
the  most  prominent  portion  of  the  tuber  ischii,  the  acetabulum 
will  be  approximately  bisected,  the  line  passing  just  across  the 
tip  of  the  great  trochanter.  This  is  known  as  Nelaton's  line  and 
forms  the  dividing  line  between  anterior  and  posterior  luxations. 


Fig.   576. — High    dorsal    dislocation    of    the   hip    -with    eversion    or    outward    rotation 
which  is  only  possible  when  the  outer  arm  of  the  Y-ligament  is  ruptured. 

If  the  head  lies  posterior  to  this  line  the  condition  will  be  know^n 
as  a  posterior  dislocation  and  the  exact  position  at  which  the  head 
comes  to  rest  will  determine  the  type  of  backward  luxation  present. 
In  like  manner  anterior  dislocations  are  subdivided  according  to 
the  point  at  which  the  head  comes  to  rest  in  front  of  Nelaton's 
line.  The  more  usual  dislocations  occurring  at  the  hip  ma^^  be 
classified  as  follows : 


Posterior  luxations 


Anterior  luxations 


rlliac 
\Sciatic 

Ilio-peetineal 
Pubic 
Obturator 
-Perineal 


520  FRACTURES   AND   DISLOCATIONS 

Extreme  and  unusual  conditions  sometimes  occur  l)ut  for  prac- 
tical purposes  it  is  inadvisable  to  attempt  their  consideration  in  a 
elassilication.  '  In  eases  of  great  violence,  in  wliicli  the  Y-ligament 
is  torn,  the  head  may  lie  anywhere  in  this  region  and  the  symp- 
toms accompanying  the  dislocation  will  be  atypical.  The  condition 
may,  in  rare  instances,  be  comitound  or  comi)licated  by  fracture. 

Etiology. — Dislocations  of  the  hip  constitute  from  one  to  two 
percent  of  all  luxations.  They  occur  most  frequently  between  the 
fifteenth  and  forty-tifth  years,  altliough  they  may  be  seen  at  any 
age.  Tlie  increasing  brittleness  of  the  bones  as  age  advances,  ren- 
ders dislocation  extremely  uncommon  in  the  aged.  It  occurs  about 
eight  times  more  often  in  males  than  in  females.  Of  the  various 
types  of  displacements,  the  dorsal  iliac  is  by  far  the  most  common. 
Next  in  order  of  frequency  is  the  obturator,  a  sul)division  of  the 
anterior. 

Symptoms. — Severe,  sickening,  localized  pain,  loss  of  function, 
and  restricted  mobility  are  symptoms  which  are  common  to  all 
forms  of  dislocation  of  the  hip.  Deformity,  however,  will  vary 
with  the  position  occupied  by  the  displaced  femoral  head. 

In  the  iliac  type,  the  head  of  the  bone  lies  above  and  behind  the 
acetabulum,  being  prevented  from  occupying  a  higher  position  by 
the  restraining  action  of  the  untorn  ilio-femoral  ligament.  The 
thigli  is  slightly  flexed,  rotated  inward,  somewhat  adducted,  and 
apparently  shortened  to  the  extent  of  about  two  inches.  The  pa- 
tient's suffering  is  greatly  increased  and  rigid  resistance  is  felt 
when  passive  motion  is  attempted,  especially  abduction.  A  com- 
plication of  this  condition  is  occasionally  observed  wlien  the  upper 
posterior  portion  of  the  rim  of  the  acetabulum  is  fractured,  and  the 
fragment  displaced  with  the  head.  Under  these  circumstances,  the 
head  leaves  the  socket  at  the  point  of  fracture  instead  of  through 
the  usual  rent  in  the  lower  part  of  the  capsule.  Reduction  may  be 
possible  by  simple  traction,  since  the  obstructing  portion  of  the 
acetabular  rim  is  no  longer  intact.  Crepitus  may  occur  as  the 
serrated  surfaces  pass,  often  rendering  the  condition  extremely 
diiBeult  to  differentiate  from  fracture  of  the  femoral  neck.  The 
condition  might,  more  properly,  be  described  as  a  fracture  of  the 
acetabulum,  complicated  by  dislocation.  In  iliac  luxation  of 
the  hip  there  is  no  tendency  towards  spontaneous  recurrence  of 
deformity  following  reduction,  unless  the  condition  is  complicated 
by  fracture  of  the  acetabular  rim.     In  simple  dorsal  dislocations, 


DISLOCATIONS   OP   THE   HIP 


521 


passive  flexion  of  the  thigh  meets  with  less  resistance  than  motion 
in  any  other  direction.  Loss  of  function  is  complete.  There  are  a 
few  reported  cases  of  dorsal  dislocation  with  eversion  of  the  thigh 
as  a  result  of  laceration  of  the  anterior  arm  of  the  Y-ligament. 

The  head  of  the  hone  may  lie  in  the  sciatic  notch,  instead  of  on 
the  dorsum  of  the  ilium,  the  condition  then  being  known  as  the 
sciatic  form  of  posterior  dislocation.     Under  such  circumstances, 


Fig.    577. 


Fig.    578. 


Fig.  5  77. — Attitude  in  dorsal  luxation  of  tlie  hip.  Tliigli  shortened,  adducted  and 
rotated  inward. 

Fig.  578. — ^Attitude  in  anterior  luxation  of  the  hip.  Thigh  lengthened,  abducted  and 
rotated  outward. 


flexion  and  adduction  of  the  thigh  will  be  more  pronounced.  We 
have  practically  the  same  dislocation  whether  the  head  lies  in  the 
sciatic  notch,  or  on  the  dorsum  ilii,  the  difference  being  one  of 
degree  only.  As  previously  explained,  the  determining  factor  be- 
tween these  two  types  of  posterior  dislocation,  is  the  obturator 
internus. 

The  symptoms  in  forward  dislocation  are  the  same  as  those  just 
described  as  far  as  pain  and  loss  of  function  are  concerned.     The 


522 


FRACTURES   AND   DISLOCATIONS 


deformity,  however,  is  unlike  that  seen  in  posterior  luxations  be- 
cause of  the  difference  in  the  positions  occupied  by  the  head. 

In  the  ilio-pcctineal  luxation,  the  head  rests  on  the  horizontal 
ramus  of  the  pubis,  in  the  region  of  tlio  ilio-pectineal  eminence,  in 
which  position  it  may  be  palpated.  Oiitwai'd  rotation  is  marked, 
thougli  abduction  and  flexion  arc  slight,  if  present  at  all.  The 
capsular  rent  is  in  the  lower  or  lower  anterior  j^ortion  of  the  liga- 
ment. Numbness  and  pain  may  be  present  along  the  course  of 
the  anterior  crural  nerve  if  pressure  has  been  exerted  upon  it  by 
the  displaced  head.     Pressure  upon  or  injury  to  the  femoral  ves- 


Fig.   5  79. 


Figs.  579  and  580. — Old  unreduced  dorsal  dislocation  of  left  hip  of  thirty-five  years' 
standing.  Patient  unable  to  fully  extend  thigh  though  able  to  get  about  by  the  aid  of 
a  built-up  shoe  and  cane.  Note  the  shortening,  adduction  and  inward  rotation  of 
thigh.  The  shortening  is  more  pronounced  than  is  usual  iu  recent  cases.  (Toes  of 
left   foot   lost   through   freezing. ) 


sels  has  been  observed  in  some  instances.  Slight  shortening  of  the 
lower  extremity  usually  exists,  and  passive  motion,  especially  in- 
ward rotation,  meets  with  solid  resistance. 

If  the  head  of  the  bone  continues  further  in  its  inward  course, 
it  may  come  to  rest  on  the  symphysis  pubis  or  above  the  liorizontal 
ramus,  the  dislocation  then  being  spoken  of  as  symphyscal  or  supra- 
pubic. These  two  conditions  are  but  exaggerated  forms  of  the 
ilio-pectineal  luxation,  and  accordingly  the  symptoms  will  be  more 
pronounced  and  the  danger  to  the  anterior  crural  nerve  and  femoral 
vessels  is  greater.     In  either  of  these  forms  the  head  of  the  bone 


DISL0CATI0N8   OF   THE   HIP  523 

may  be  felt  as  a  slol)iilHr  |))'Oiiii)ieiK'e  somewhere  along  the  hori- 
zontal ramus  of  the  pubis. 

A  few  cases  have  been  reported  in  which  the  head  occupied  an 
extremely  high  position,  directly  below  the  anterior  superior  iliac 
spine.  This  is  !)ut  a  variation  of  the  ilio-pectineal  form,  and  is 
exceedingly  rare. 

In  the  obturator  dislocation,  another  form  of  anterior  displace- 
ment, the  head  of  the  bone  fails  to  ride  upward  after  leaving  the 
acetabulum  but  comes  to  rest  in  the  obturator  foramen.  This  form 
of  dislocation  is  next,  in  point  of  frequency,  to  the  iliac  type. 
The  limb  is  slightly  flexed,  abducted,  and  rotated  outward,  and 
the  displaced  head  may  be  palpated  without  difficulty.  A  depres- 
sion is  noted  in  the  position  formerly  occupied  by  the  trochanter, 
the  thigh  appears  lengthened  and  full  extension  is  not  possible. 

The  perineal  luxation  is  simply  an  exaggeration  of  the  obturator 
form  of  displacement,  in  which  the  symptoms  (especially  abduc- 
tion) are  more  pronounced.  The  condition  is  very  unusual.  The 
prominence  produced  by  the  head  may  be  recognized  both  by  in- 
spection and  palpation.  The  ischio-pubic  rami  may  be  fractured 
as  the  head  passes  across  this  portion  of  the  pelvis  into  the  perineum. 

There  is  an  extremely  rare  form  of  downward  luxation  known 
as  the  infra-cotyloid,  which  is  analogous  to  the  luxatio  erecta  oc- 
curring in  the  shoulder.  The  head  of  the  bone  is  forced  from  the 
acetabulum  while  the  thigh  is  in  extreme  flexion,  and  rests  in  dis- 
placement on  the  body  of  the  ischium.  The  thigh  is  maintained  in 
extreme  flexion  until  the  head  is  replaced.  This  condition  can 
neither  be  classed  with  the  anterior,  nor  with  the  posterior  dislo- 
cations, since  the  head  is  crossed  by  Nelaton's  line.  This  luxation 
is  so  extremely  rare  that  it  might  better  be  considered  as  a  surgical 
anomaly  rather  than  to  describe  it  as  a  type. 

Another  very  unusual  displacement  is  known  as  central  dislo- 
cation of  the  hip,  in  which  the  head  is  driven  through  the  bottom 
of  the  acetabulum.  This  condition  has  already  been  described  on 
page  504  under  "Fractures  of  the  Lateral  Portions  of  the  Pelvis." 

Diagnosis. — The  diagnosis  is  based  on  the  sjnnptoms  just  de- 
scribed. Recognition  of  the  condition  is  seldom  really  difficult, 
although  it  is  not  uncommon  to  see  a  dislocation  of  the  hip  mis- 
taken for  fracture  of  the  femoral  neck,  or  even  confounded  with 
some  forms  of  pelvic  fracture.  The  fact  that  the  usual  impacted 
fracture  of  the  neck  of  the  femur  should  not  be  broken  up,  renders 


524  FRACTURES    AND    DISI.OCATIOXS 

it  ossontial  tliat  the  surgeon  be  at  least  reasonably  sure  of  the 
existinji'  conditioiis  hcfoi-e  an  attempt  is  made  at  the  reduction  of 
a  luxated  hip.  In  fracture  of  the  neek  witli  impaction,  the  lower 
extremity  lies  in  a  helpless  attitude,  shows  some  shortening  and 
slight  outward  ]-otation.  There  is  no  abnormal  fixation  of  the 
parts  aside  from  that  iJi'oduced  b>-  i-cflcx  inusculai-  spasm.  Inward 
rotation  is  extremely  rare  in  fracture  of  tlie  femoral  neck.  The 
most  connuon  dislocation  of  the  hip  is  the  dorsal,  in  which  adduc- 
tion and  inwai'd  rotation  arc  pronounced. 

The  great  majority  of  dislocations  are  on  to  the  dorsum  of  the 
ilium  or  into  the  obturator  foramen,  and  the  characteristic  de- 
formities a('comi);myiiig  these  displacements  will  suggest  the  con- 
dition when  the  case  is  first  inspected.  In  dislocations  it  will 
usually  be  possible  to  palpate  the  femoral  head,  which  is,  of  course, 
impossible  in  fractures  of  the  neck.  In  dislocations,  mobility  at 
the  hip  is  much  restricted  in  contradistinction  to  the  normal  mo- 
bility seen  in  impacted  fractures,  and  the  increased  mobility  occur- 
ring in  fractures  of  the  unimpacted  type.  In  dislocations  crepitus 
is  absent ;  in  fractures  it  can  almost  invariably  be  elicited.  Dorsal 
dislocation  with  fracture  of  the  acetabular  rim,  nuiy  be  quite  diffi- 
cult to  differentiate  from  fracture  of  the  femoral  neck.  Crepitus 
may  be  present  in  either  injury.  In  the  former,  motion  is  re- 
stricted as  in  all  uncomplicated  dislocations  of  the  hip,  while  in 
the  latter,  it  may  be  restricted  or  abnormally  increased.  Reduc- 
tion of  a  simple  doj-sal  dislocation  is  only  accomplished  by  some 
system  of  manipulations,  such  as  Bigelow's,  while  on  the  other 
hand,  displacement  accompanying  fracture  of  the  acetabular  rim 
may  be  reduced  without  difficulty  by  simple  traction  and  counter- 
traction,  and  there  is  a  strong  tendency  towards  spontaneous  re- 
currence of  deformity. 

In  fractures  it  is  almost  always  possible  to  rotate  the  thigh,  and 
with  the  finger  placed  on  the  trochanter,  the  arc  described  by  the 
femoral  neck  can  be  ascertained  and  compared  with  the  uninjured 
side,  and  the  surgeon  can  estimate  whether  or  not  the  center  of 
this  arc  is  in  the  acetabulum.  In  dislocations  the  fixity  of  the 
thigh  precludes  anything  but  the  slightest  rotation.  When  doubt 
exists  as  to  the  nature  of  the  injury  the  X-ray  should  be  employed 
to  clear  up  the  diagnosis. 

Treatment. — The  first  indication  of  treatment  is  the  reduction 
of  the  displaced  head.     The  method  of  accomplishing  this  purpose 


DISLOCATIONS    01^    THE    HIP 


525 


must,  of  necessity,  vary  with  the  type  of  dislocation  present.  The 
object  in  all  instances  is  to  cause  the  head  to  retrace  the  course 
taken  by  it  in  leaving  the  cavity.  All  manipulations  must  be 
performed  with  due  appreciation  of  the  strength  and  attachments 
of  the  ilio-fe moral  ligament  (see  ''Anatomy,"  page  516).  It  should 
be  distinctly  understood  that  the  common,  dorsal  dislocation  can- 
not be  dragged  back  into  position  by  simple  traction  and  counter- 
traction  without  the  employment  of  excessive  and  unnecessary  force 
and  rupture  of  the  ilio-femoral  ligament.  Reduction  must  be  ac- 
complished by  manipulation. 


Fig.  581. — Reduction  of  the  common  backward  dislocation  of  the  hip  (see  text). 
In  Bigelow's  method  the  thigh  is  tlexed  to  a  right  angle,  adducted,  rotated  inward, 
lifted,  circumducted  outward  and  extended.  The  lifting  of  the  thigh  is  the  essential 
step  in  the  reduction  of  backward  dislocations  and  may  be  aided  by  counter-pressure 
with  the  unbooted  foot  as  shown  in  this  plate.  In  Bigelow's  method  of  reducing  an- 
terior luxations  the  thigh  is  flexed  to  a  right  angle  (as  shown  in  this  illustration), 
abducted,  rotated  inward,  adducted  and  extended.  This  modification  is  readily  under- 
stood if  the  position  of   the  head  in   anterior  luxations   is  kept   in  mind. 

In  reducing  a  dorsal  dislocation,  the  first  step  consists  in  flexing 
the  thigh  to  a  right  angle,  which  move  relaxes  the  Y-ligament. 
Traction  is  then  made  in  the  line  of  the  axis  of  the  semi-flexed 
femur,  which  draws  the  head  of  the  bone  up  on  to  and  over  the 
acetabular  rim.  Outward  rotation  is  then  performed,  and  the  thigh 
allowed  to  gradually  assume  the  horizontal,  or  extended  position. 
The  head  of  the  bone  should  slip  back  into  the  socket  as  outward 
rotation  is  commenced,  or  during  the  first  part  of  extension.  The 
most  essential  part  of  this  manipulation  (Bigelow's  method)  con- 
sists in  drawing  the  femoral  head  forward  from  the  dorsum  of  the 
ilium  over  the  acetabular  rim. 


526 


FRACTURES   AND   DISLOCATIONS 


Fig.  582. — Stimson's  inetliod  of  redufiiij;  in>st(M'ior  lu.xations.  Tlie  weight  of  the 
lower  extremity  pulls  in  the  direction  indicated  by  the  arrow  and  this  alone  may  be 
sufficient  to  effect  reduction.  Downward  pressure,  however,  with  the  hand,  as  shown, 
will  render  the  method  more   certain.      (See  text.) 


Fig.  583. — Author's  modification  of  Bigclow's  nietliod.  The  thigh  is  "lifted"  (raised 
sky-ward)  by  the  surgeon's  shoulder  while  counter-pressure  is  exerted  on  tlie  anterior- 
superior  iliac  spine.  Tlie  opposite  liand  exerts  direct  pressure  on  the  trochanter  and 
prevents  it  from  riding  around  the  rim  of  the  acetabulum.  (See  text.)  It  has  been  the 
author's  experience  that  difficult  cases  may  be  handled  in  this  way  after  the  nnmodified 
Bigelow's  method  has  failed.  An  anesthetic  is  often  essential  to  the  reduction  of  dis- 
locations of  the  hip,  especially  in  well-muscled  persons. 


DISLOCATIONS   OF    THE   HIP  527 

The  author  has  found  the  following  original  method  of  accom- 
plishing this  result  successful  in  instances  in  which  the  above  ma- 
nipulation failed.  With  the  hip  and  knee  flexed  at  right  angles 
the  surgeon  places  his  shoulder  under  the  bend  of  the  knee,  one 
hand  is  placed  on  the  anterior  superior  iliac  spine,  while  the  oppo- 
site hand  grasps  the  trochanter,  and  exerts  pressure  in  the  desired 
direction.  In  this  position  forward  traction  is  made  by  raising 
the  shoulder,  direct  manipulation  is  had  by  the  hand  on  the  tro- 
chanter, while  counter-traction  is  exerted  through  the  hand  resting 
on  the  iliac  spine.  During  this  manipulation  an  assistant  should 
securely  hold  the  patient's  ankle,  thus  fixing  the  lower  leg.  Ac- 
cording to  instructions  issued  by  the  surgeon  to  his  assistant  during 
manipulation  the  ankle  may  be  carried  away  from,  or  toward  the 


Fig.  584. — Allis'  method  of  securing  tlie  pelvis  to  the  floor  while  reducing  luxa- 
tions of  the  hip.  Three  staples  are  driven  into  the  floor  and  the  pelvis  secured  as 
shown. 

median  plane,  thus  producing  inward  or  outward  rotation  of  the 
thigh  as  desired.  In  this  way  the  head  may  be  controlled,  and 
forced  up  on  to  the  slope  of  the  acetabulum,  rather  than  allowing 
it  to  ride  about  the  margins  of  the  rim.  (See  Fig.  583.)  No 
originality  is  claimed  for  the  principles  involved  in  this  manipu- 
lation since  it  is  only  a  modification  of  Bigelow's  method.  AYhen, 
however,  difficulty  is  experienced  in  forcing  the  head  of  the  femur 
over  the  rim  of  the  acetabulum  this  manipulation  will  be  found 
much  more  efficient  than  the  regular  Bigelow's  method. 

Stimson's  method  is  as  follows:  The  patient  is  placed  face 
downward  on  a  table.  The  injured  thigh  is  allowed  to  hang  over 
the  edge  of  the  table  at  a  right  angle,  while  the  uninjured  extremity 
is  maintained  in  the  horizontal  position  by  an  assistant  to  steady 


528  FRACTURES   AND   DISLOCATIONS 

the  pelvis.  The  surgeon  tlien  flexes  the  knee,  and  the  weight  of 
the  knee,  with  the  muscles  relaxed,  is  said  to  be  sutidcient  to  ett'ect 
reduction.  Slight  rotation  and  downward  traction  will  assist  in 
accomplishing  the  return  of  the  head  to  the  acetabulum.  This 
method  works  nicely  in  some  cases,  though  it  is  by  no  means  as 
efficient  as  Stimson's  method  of  effecting  reduction  in  dislocations 
of  the  shoulder. 

All  of  the  above  methods  are  based  on  the  same  principles: 
namely,  bringing  the  head  opposite  the  capsular  rent  by  flexion 
and  rotation  of  the  thigh,  and  then  forcing  the  head  over  the 
acetabular  rim  and  through  the  capsular  rent  by  traction  in  the 
line  of  the  axis  of  the  femur. 

Allis  fully  appreciated  the  value  of  fixation  of  the  pelvis  and 
advises  having  it  secured  to  the  floor  by  means  of  a  sj^stem  of  screw 
eyes  and  bandages  (see  Fig.  584)  or  else  by  means  of  assistants. 
This  however  will  not  be  necessary  if  the  author's  modification  of 
Bigelow's  method  is  employed. 

The  reduction  of  anterior  displacements  is  accomplished  by  the 
same  principles  as  already  described,  although  the  difference  in 
the  position  of  the  head  will  necessitate  different  manipulations  to 
bring  the  head  opposite  the  capsular  rent. 

The  ilio-pectineal  dislocation  and  its  variations  along  the  hori- 
zontal ramus  of  the  pubis  are  reduced  as  follows :  extension  is 
made  to  bring  the  head  downward  as  far  as  possible  so  that  flexion 
can  be  accomplished.  The  thigh  is  then  flexed  at  a  right  angle 
with  the  body,  while  direct  pressure  is  made  upon  the  head  to 
prevent  its  slipping  upward.  Inward  rotation  and  traction  in  the 
line  of  the  axis  of  the  femur  are  then  performed  to  return  the 
head  to  the  socket.  The  last  step  in  this  manipulation  is  similar 
to  that  already  described  under  dorsal  dislocations. 

The  obturator  dislocation  and  its  exaggerated  form,  the  perineal 
type,  are  reduced  in  much  the  same  manner  as  dorsal  dislocations 
after  the  head  has  been  brought  opposite  the  capsular  rim.  The 
steps  are :  flexion  of  the  thigh  to  a  right  angle,  traction  in  the 
line  of  the  axis  of  the  femur,  and  then,  abduction  and  outward  ro- 
tation.    The  limb  is  then  extended. 

Central  dislocations  of  the  hip  are  reduced  by  outward  traction 
on  the  upper  end  of  the  thigh  while  the  knee  is  fixed.  The  condi- 
tion is  more  properly  a  fracture  than  a  dislocation.     Buck's  exten- 


DISLOCATIONS   OF    THE   HIP  529 

sion  is  indicated  for  from  six  to  eight  weeks  and  direct  outward 
traction  on  the  upper  portion  of  the  thigh  should  he  maintained, 
according  to  the  Ruth-Maxwell  method,  to  prevent  the  muscles 
attached  to  the  upper  femur  from  pulling  the  head  through  the 
acetabulum  into  the  pelvis.  (See  "Ruth-Maxwell  method,"  page 
545.) 

The  strength  of  the  muscles  and  the  pain  accompanying  manipu- 
lations renders  an  anesthetic  essential  in  the  reduction  of  hip  dis- 
locations. 

Operative  Treatment. — Nearly  all  dislocations  of  the  hip  can  be 
reduced  by  proper  manipulation  under  anesthesia,  though  occa- 
sionally it  is  impossible  to  return  the  head  to  the  socket,  unless 
recourse  is  had  to  operative  methods.  A  vertical  incision  in  the 
region  of  the  trochanter  can  be  so  made  as  to  expose  the  parts 
involved.  When  inward  rotation  is  present  the  incision  should 
be  made  a  little  behind  the  trochanter;  when  outward  rotation  is 
present  the  incision  should  be  anterior  to  the  trochanter  to  prop- 
erly expose  the  head  and  neck.  A¥ith  the  parts  opened,  the  cap- 
sular rent  and  the  course  taken  by  the  head  after  leaving  the  cavity 
of  the  acetabulum  may  be  readily  recognized,  and  by  the  proper 
manipulation,  the  head  may  be  made  to  retrace  its  course  back  to 
the  socket.  Obstructions  to  reduction  are  to  be  removed  when 
present.  With  the  head  again  in  the  acetabulum,  the  capsular  rent 
should  be  sutured,  muscular  structures  approximated  and  the  skin 
incision  closed. 

Old,  unreduced  dislocations  are  the  ones  most  frequently  de- 
manding operative  reduction.  When  the  head  of  the  bone  has 
been  out  of  the  socket  for  some  time,  fibrous  tissue  forms  about  it 
in  such  a  manner  that  partial  restoration  of  function  results.  The 
action  of  the  thigh,  however,  is  always  more  or  less  impaired  be- 
cause, if  for  no  other  reason,  the  upper  end  of  the  femur  is  "off- 
center"  with  relation  to  the  muscles  of  the  hip.  Partial  or  com- 
plete healing  of  the  capsular  rent  often  renders  it  impossible  to 
accomplish  reduction  by  simple  manipulation.  If  some  months 
have  elapsed  since  the  accident  the  acetabulum  may  become  filled 
with  fibrous  tissue,  which  must  be  removed  with  a  heavy  curette  or 
chisel  before  the  head  of  the  bone  can  be  made  to  fit  it.  The  joint 
is  approached  through  a  lateral,  vertical  incision,  as  already  de- 
scribed, which  varies  somewhat  with  the  type  of  dislocation  present. 


530  FRACTURES   AND   DISLOCATIONS 

Contractiiivs  in  tlic  tliigli  nmsclos  soini^inios  nocessitnti'  tiaiisverse 
cutting  of  eitlifi-  tciulous  or  niuscU's  before  tiie  head  of  tlie  bone 
ean  be  retui-ned  to  llie  socket. 

After- Treatment.  Following  reduction  of  a  recent  dislocation 
llie  pal  lent  .slioidd  be  kept  at  rest  in  bed  for  a  period  of  from  two 
to  four  weeks,  according  to  the  age  of  the  individual  and  the  sever- 
ity of  the  condition.  JMassage  and  passive  motion  are  of  service 
in  maintaining  the  muscular  tone  of  the  lower  extremity.  In  the 
performance  of  passive  motion,  however,  abduction  should  be 
avoided,  since  this  is  the  jiosition  in  which  the  head  probably  left 
the  cavity.  Central  dislocations  and  dorsal  dislocations  compli- 
cated by  fracture  of  the  acetabular  ring  require  Buck's  extension 
apparatus  to  maintain  reduction.  In  addition  central  dislocation 
calls  for  lateral  traction  of  the  thigh.  These  appliances  should 
be  kept  in  use  for  a  period  of  six  weeks.  During  the  after-treat- 
ment the  weights  employed  in  the  traction  apparatuses  may  be 
reduced  as  the  muscular  spasm  grows  less.  The  resumption  of 
function  should  l)e  gradual  after  the  patient  has  recovered  suffi- 
ciently to  leave  his  bed.  He  should  be  instructed  to  particularly 
avoid  any  position  of  the  thigh  similar  to  the  attitude  in  which 
dislocation  occurred. 

Prognosis. — The  outlook  in  uncomplicated  dislocations  of  the  hip 
is  good  if  reduction  is  accomplished  early  and  sufficient  time  allowed 
for  the  repair  of  the  parts  before  function  is  resumed.  Central 
dislocation  of  the  hip  is  a  much  more  serious  condition,  since  it 
includes  fracture  of  the  pelvis  and  may  be  accompanied  by  injury 
to  the  pelvic  viscera.  Proper  operative  procedures  are  usually  fol- 
lowed by  improvement  of  function,  though  it  is  seldom  possible  to 
secure  a  perfect  restoration,  if  the  head  of  the  bone  has  been  out 
of  the  socket  for  any  considerable  length  of  time. 


CHAPTER  XXXVII. 

FRACTURES  OF  TPIE  UPPER  END  OF  THE  FEMUR. 

Surgical  Anatomy. — The  upper  end  of  the  femur  has  three 
accessory  centers  of  ossification ;  one  for  the  head,  one  for  the 
greater,  and  one  for  the  lesser  trochanter.  They  all  join  the 
diaphysis  at  about  the  eighteenth  year.  Epiphyseal  separations, 
however,  are  extremely  rare  in  the  upper  end  of  this  bone,  except 
as  a  chronic  condition  in  children,  which  is  known  as  coxa  vara. 
(See  "Injuries  to  the  Femoral  Neck  in  Children,"  page  555.)  The 
structure  of  the  upper  end  of  the  femur,  including  the  relation  of 
compact  and  cancellous  tissue,  is  of  importance  in  explaining  many 


i'ig.    585. 


Figs.  535  and  586. — Coronal  and  nearly  horizontal  sections  of  the  upper  end  of 
the  femur  showing  the  relative  distribution  of  cancellous  and  compact  tissue.  H.,  head 
of    femur.      T.,    trochanter    major.      (Preston — Surg.,    Gynecol,    and    Obstet.,    Feb.,    1914.) 

of  the  clinical  conditions  occurring  in  fractures  (see  Figs.  585 
and  586).  The  upper  end  of  the  bone  is  composed  of  wide-meshed 
cancellated  tissue,  enclosed  in  a  layer  of  compact  structure  which 
grows  heavier  as  the  shaft  is  approached.  Closer  examination  of 
the  cancellous  tissue  shows  that  it  is  disposed  in  two  sets  of  planes, 
the  socalled  "tension  planes"  and  "pressure  planes."  The  former 
run  upward  from  the  outer  portion  of  the  shaft  into  the  trochanter, 
and  arch  over  into  the  neck  and  head ;  the  latter  ascend  from  the 

531 


532  FRACTURES   AND   DISLOCATIONS 

inner  side  of  the  shaft  and  pass  into  the  head,  while  othei*s  arch 
over  to  the.  great  troelianter.  These  planes  are  simply  an  arrange- 
ment of  the  cancellous  tissue  whicli  renders  the  same  amount  of 
bone  more  capable  of  withstanding  the  pressure  and  tension  to 
which  the  femur  is  subjected  by  use.  The  calcar  femorale  is  a 
thickening  in  the  internal  structure  of  the  neck  which  strengthens 
the  angle  of  junction  between  neck  and  shaft. 

The  neck  joins  the  shaft  at  an  angle  of  about  127  degrees,  al- 
though variations  occur  between  the  limits  of  121  and  14-1  degrees. 
In  children  the  angle  is  more  obtuse,  while  in  old  age  it  approaches 
the  right  angle.  The  great  trochanter  is  often  traversed  by  a 
continuation  of  the  compact  tissue  of  the  posterior  surface  of  the 
neck,  and  although  this  tends  to  strengthen  the  posterior  aspect 
of  the  neck,  yet  the  arrangement  is  not  as  strong  as  that  found 
anteriorly. 

Numerous  muscles  are  attached  to  the  upper  end  of  this  bone, 
which  influence  the  relative  positions  of  the  fragments  in  the  pres- 
ence of  unimpacted  fracture  of  the  neck,  liaising  of  the  lower 
fragment  or,  in  other  words,  shortening  of  the  lower  extremity,  is 
brought  about  by  the  action  of  the  ham-string  muscles,  the  adductor 
group,  the  glutei,  rectus,  sartorius,  ilio-psoas,  tensor  vaginae  femoris, 
pectineus  and  gracilis.  Eversion  of  the  lower  extremity  is  the 
result  of  the  weight  of  the  thigh,  the  center  of  gravity  being  ex- 
ternal to  the  articulation  of  the  hip.  Eversion,  in  impacted  cases, 
is  due  to  the  manner  in  which  the  base  of  the  neck  is  driven  into 
the  trochanter  and  the  fact  that  the  anterior  portion  of  the  femoral 
neck  is  stronger  than  the  posterior.  In  addition  to  the  action  of 
the  pectineus  and  the  adductor  muscles,  it  will  be  observed  that  all 
the  glutei  tend  to  i)roduce  outward  rotation. 

Fractures  may  occur  in  the  neck,  close  to  the  head,  midway  be- 
tween the  head  and  the  great  trochanter,  or  at  the  base  of  the  neck 
where  it  joins  the  shaft.  The  last  named  position  is  by  far  the 
most  common.  In  some  instances  the  fracture  may  pass  in  such  a 
manner  that  it  involves  the  upper  portion  of  the  femoral  shaft  as 
well  as  the  neck.  Fractures  have  been  divided  anatomically  ac- 
cording to  the  position  of  the  break  with  relation  to  the  capsule. 
Intra-capsular  fractures  show  a  much  stronger  tendency  toward 
non-union  than  those  outside  the  capsule.  Surgically,  however, 
this  distinction  is  not  of  great  value,  since  it  is  almost  impossible 
in  a  given  case  to  say  whether  the  fracture  is  within  or  outside  of 


FRACTURES   OF    UPPER   END   OP    FEMUR  533 

the  ligament.  Moreover,  post-mortem  findings  have  demonstrated 
the  fact  that  in  the  majority  of  instances  in  which  the  neck  is 
broken,  the  line  of  fracture  is  both  intra-  and  extra-capsular ;  that 
is,  the  fracture  passes  through  the  femoral  attachment  of  the  liga- 
ment. The  more  practical  distinction  is  vv^hether  or  not  the  frac- 
ture is  impacted.  Impaction  consists,  as  a  rule,  in  the  base  of  the 
neck  being  driven  into  the  substance  of  the  great  trochanter.  If 
the  neck  is  viewed  from  above  one  reason  for  the  frequency  with 
which  eversion  accompanies  impaction  will  be  apparent.  The  an- 
terior surface  of  the  neck  is  almost  straight  and  flush  with  the 
front  edge  of  the  trochanter,  thus  offering  solid  support  to  the 
anterior  portion  of  the  trochanter  in  the  presence  of  direct  vio- 
lence. The  posterior  surface  of  the  neck  is  much  curved  and  does 
not  come  flush  with  the  posterior  margin  of  the  trochanter.  This 
results  in  the  posterior  portion  of  the  trochanter  being  much  more 
poorly  supported  than  is  the  anterior,  and  when  direct  violence 
is  applied  in  this  region  of  the  bone  the  posterior  aspect  of  the 
neck  will  be  more  likely  to  give  way  than  the  anterior.  The  result 
is,  manifestly,  eversion  when  impaction  of  the  femoral  neck  occurs. 
The  continuation  of  the  compact  tissue  of  the  posterior  surface  of 
the  neck  into  the  trochanter,  previously  mentioned,  tends  to 
strengthen  this  portion  of  the  bone ;  yet  this  bony  tissue  is  variable 
and  even  when  present  is  not  sufficiently  heavy  to  increase  the 
strength  of  the  posterior  aspect  of  the  femoral  neck  so  that  it  equals 
that  found  in  the  anterior  portion.  When  the  ring  of  compact 
tissue  surrounding  the  junction  of  the  neck  and  shaft  is  fractured, 
the  neck  crushes  into  the  cancellous  tissue  of  the  trochanter  with 
comparatively  little  resistance. 

The  surgeon  should  know  the  bony  landmarks  in  this  region  to 
be  able  to  properly  diagnose  and  treat  fractures  of  the  femoral 
neck.  The  crest  of  the  ilium  is  subcutaneous  throughout,  the  great 
trochanter  can  be  recognized  both  by  inspection  and  palpation, 
and  the  tuberosity  of  the  ischium  can  be  readily  felt.  The  rela- 
tive positions  of  the  anterior  superior  iliac  spine,  tuber  ischii  and 
trochanter  major  should  be  known  under  normal  conditions  in 
order  that  the  variations  occurring  in  fractures  may  be  recognized. 
If  a  tape  is  stretched  between  the  anterior  superior  iliac  spine  and 
the  tuberosity  of  the  ischium  it  will  correspond  to  Nelaton's  line 
(see  Fig.  587).  Normally  Nelaton's  line  about  touches  the  top  of 
the  great  trochanter.     In  fracture  of  the  femoral  neck  with  short- 


534 


FRACTURES   AND   DISLOCATIONS 


t'liiiio:,  the  to])  of  till'  trocliaiitcr  rises  above  this  lino.  Tlie  fascia 
lata,  composed  of  heavy  lihroiis  tissue,  is  attacheii  above  to  the 
outer  lip  of  the.  iliac  crest,  and  below  to  the  external  tuberosity  of 
the  tibia.  I'lidei-  normal  conditions  this  fascia  is  tense  and  otfers 
resistance  when  |)i('ssuri'  is  made  between  the  iliac  crest  and  tro- 
chanter: when  IVactui-e  or  disease  of  tlu'  femoral  neck  results  in 
shoi'tenint:-.  this  portion  of  the  fascia  lata  becomes  lax,  which  con- 
dition  may   lie  recognized  by  comparison   with  the  opposite  side. 

The  rarifyinp:  changes  or  osteoporosis  occun-ing  in  old  age  affect 
the  ciilii-e  iiilei'iial  sti'uctui'e  o f  the  upper  end  of  the  femur,  and 
tend  to  remove  the  calcar  i'emorale,  and  the  extension  of  the  pos- 
terior surface  of  the  neck  which  continues  into  the  substance  of 
the  trochanter.     In  addition,  the  surface  compact  tissue  becomes 


Fit;.  587. — Miipijin^;-  mil  uf  J-!r>  aiil'.s  triangle  ami  Nc'lalon's  li)U'.  A  line  drawn 
from  the  anterior  superior  iliac  spine  to  the  tuberositj'  of  the  ischium  is  known  as 
Nelaton's  line  and  should  about  touch  the  top  of  tlie  great  trochanter.  (See  Fig.  600.) 
A  vertical  line  dropped  from  the  anterior  superior  iliac  spine  to  the  table  on  which 
the  patient  lies  and  a  vertical  line  extended  upward  from  the  top  of  the  great  trochanter 
form  two  sides  of  Bryant's  triangle  while  the  third  side  is  formed  by  Nelaton's  line. 
Bryant's  triangle — X.Y.Z.  In  fractures  of  the  femoral  neck  the  distance  Y.Z.  is 
usually  shortened.  A.fi.,  the  anterior  superior  iliac  spine.  S.,  Symphysis  pubis.  T.I., 
Tuber   ischii. 


thinner  and  more  brittle.  These  changes  togetlier  with  the  alter- 
ation in  the  angle  at  which  the  neck  joins  the  shaft  explain,  at 
least  partially,  the  frc(|uency  of  fracture  of  the  femoral  neck  in 
the  aged. 

Fracture  of  tlie  head  of  the  femur  is  an  extremely  unusual  con- 
dition, only  two  or  three  cases  having  been  reported.  It  is  not  an 
uncommon  matter  for  fractures  of  the  neck  of  the  femur  to  involve 
the  great  trochanter,  but  isolated  fractui'e  of  the  trochanter  is 
almost  as  rare  as  fracture  of  the  head.  The  cases  reported  have 
been  due  either  to  direct  violence  or  to  muscular  action.  Isolated 
fracture  of  the  lesser  trochanter  is  also  a  rare  condition.  The  re- 
ported cases  seem  to  have  been  due  to  the  action  of  the  ilio-psoas. 

Etiology. — Fracture  of  the  neck  of  the  femur  is  essentially  an 
accident    of    advanced    life.     Fractures    of    the    femur    constitute 


FRAOTITRTCS    OF    TTPPKR    END    OF    FEMTTR 


535 


Fig.   588. 


589. 


Fig.    588. — Impacted  fracture  of  base  of  femoral  neck. 

Fig.  589. — Old  ununited  fracture  of  middle  of  femoral  neck  with  upward  displace- 
ment of  lower  fragment.  The  upward  displacement  of  the  femur  is  plainly  visible  and 
the  manner  in  which  the  fascia  lata  becomes  lax  between  the  trochanter  and  iliac  crest 
is  readily  appreciated. 


Fig.   590. 


Fig.    591. 


Fig.    590. — Impacted  fracture  of  neck  of  femur. 

Fig.    591. — Fracture   of   femoral    neck   with   usual   deformity- 


-raisiug  of  trochanter. 


536 


FRACrrRKS    A\l>    DISL(irATIONS 


Fig.  592. — Fracture  of  rim  of  acetabulum.  Upper  arrow  points  to  line  of  fracture 
while  the  lower  indicates  the  detached  fragment.  Deformity  controlled  by  Buck's  exten- 
sion. 

Fig.  593. — Fracture  of  a  small  portion  of  the  great  trochanter  with  separation  of 
the  fragment.  Result  of  muscular  action.  A  condition  which  might  readily  be  over- 
looked and  considered  as  a   "sprain"   if  the  Xray  were  not  employed. 


Fig.   59  4. 


Fig.    595. 


Fig.  594. — Fracture  through  femoral  neck  about  midway  between  head  and  tro- 
chanter. Deformity   overcome   by   Buck's   extension. 

Fig.  595. — Fracture  through  base  of  femoral  neck  with  splitting  off  of  lesser  tro- 
chanter. 


FRACTURES   OF    UPPER   END   OP   FEMUR  537 

about  six  percent  of  all  fractures,  and  fractures  of  the  neck  of  the 
bone  make  up  from  one-third  to  one-fourth  of  all  femoral  frac- 
tures. More  than  half  of  the  fractures  of  the  neck  occur  after  the 
sixtieth  year.     They  are  more  common  in  women  than  in  men. 

Symptoms. — The  physical  signs  and  symptoms  in  fracture  of  the 
femoral  neck  vary  according  to  whether  or  not  impaction  exists. 
In  the  unimpacted  form  the  patient  is  unable  to  stand  on  the  in- 
jured member.  In  fact  the  lower  extremity  lies  in  an  entirely 
helpless  attitude.  Pain  is  constant,  and  increased  on  motion.  The 
limb  is  usually  completely  everted  so  that  the  outer  surface  of  the 
foot  rests  flat  on  the  bed.  The  great  trochanter  is  raised  above 
Nelaton's  line,  and  the  fascia  lata  between  the  trochanter  and  iliac 
crest  is  found  relaxed  when  compared  with  the  opposite  side.  In- 
version of  the  limb,  though  extremely  rare,  may  be  present,  instead 
of  eversion.  Crepitus  and  mobility  may  be  elicited,  but  all  manip- 
ulation should  be  most  gentle  and  guarded,  lest  impaction,  if 
present,  be  broken  up.  Rotation  is  particularly  likely  to  loosen 
the  impaction.  The  limb  is  shortened,  though  seldom  more  than 
two  inches.  The  shortening  is  usually  less  pronounced  immedi- 
ately following  the  accident  than  it  is  at  the  end  of  twenty-four  or 
forty-eight  hours.  Traction  upon  the  foot  lessens  the  shortening, 
though  recurrence  is  prompt  when  the  foot  is  released.  A  slight 
fullness  in  the  upper  portion  of  Scarpa's  triangle  is  usually  noted. 

When  the  fracture  is  impacted  most  of  the  above  described  symp- 
toms are  present  though  less  pronounced.  Slight  or  moderate 
eversion  is  usually  noted,  and  some  shortening  exists  though  it  is 
by  no  means  as  great  as  is  commonly  seen  in  unimpacted  cases. 
Crepitus  is  absent.  Pain  is  usually  present,  though  the  degree  is 
quite  variable.  Loss  of  function  is  by  no  means  as  constant  and 
pronounced  as  in  unimpacted  fractures.  In  fact,  a  patient  with  a 
firmly  impacted  fracture  of  the  femoral  neck  may  be  able  to  walk 
a  considerable  distance.  This  incomplete  loss  of  function  has  not 
infrequently  been  the  cause  of  incorrect  diagnoses,  the  condition 
having  been  mistaken  for  a  "sprain."  Impaction  of  the  fracture 
produces  some  shortening  of  the  femoral  neck,  which  may  some- 
times be  recognized  in  the  shorter  arc  described  by  the  trochanter 
when  the  thigh  is  rotated.  This  shortening,  however,  is  often  so 
slight  that  it  is  difficult  of  recognition,  and  since  rotation  is  so 
likely  to  break  up  impaction  it  will  usually  be  best  to  pass  lightly 
over  this  symptom.     The  history  given  in  the  usual  ease  of  frac- 


538 


FRACTURES    AND    DISLOCATIONS 


Kii;.    ji)t). — liiipai-lcd    riiiitiu 
inpseiit   and  cversion    is  diily 


r    of     Ihr 

lIKldclMll 


\'rrv    sli-iil    (Ir-n 


if    sliorten- 


Fit;.  597. — Iiiip:u-ted  I'ruituie  of  tlie  neik  of  tlic  fciiuir  in  an  old  man.  The  limb 
is  helpless.  Very  slight  eversion  and  shorteninK  pre.sent.  There  is  no  appearance  of 
twisting  of  the  thigh  as  seen  in  Fig.  626,  nor  is  there  cany  thickening  of  the  thigh  as 
seen  in  Fig.  598.  Riintgenogram  shows  fractnre  of  the  femoral  neck.  It  is  this  type 
of  case  which  is  so  often  overlooked  and  diagnosed  as  a  "sprain"  esijecially  if  the  pa- 
tient is  able  to  walk. 


Fig.  o'JS. —  Fracture  of  riglit  femur  through  great  trochanter.  Note  thickening  of 
the  thigh  in  its  upper  part  and  the  evsrsion  of  the  lower  extremity.  Compare  the  levels 
of  the  two  knees  which  are  directly  in  front  of  the  camera.  Right  thigh  slightJy  shorter. 
Picture  taken   a  few   minutes  following  the   injury. 


Fig,    599. — Fracture   just  below   the   great  trochanter.      Note   the  eversion    and   shortening. 


PRACTTIRES   OF    UPPER   END   OF   FEMUR 


539 


ture  of  the  femoral  neck  in  elderly  persons  is  one  of  slight  trauma, 
such  as  a  misstep,  a  twist  of  the  thigh,  or  a  fall  in  walking  across 
the  room.  It  is  sometimes  difficult  to  ascertain  whether  the  fall  pro- 
duced the  fracture,  or  whether  the  fracture  was  spontaneous  and 
resulted  in  the  fall. 

Diagnosis. — The  deep  position  of  the  femoral  neck,  surrounded 
by  heavy  muscles  and  fasciae  renders  palpation  of  this  portion  of 
the  bone  extremely  difficult.  The  diagnosis  is  based  on  the  symp- 
toms just  described,  together  M'ith  a  careful  examination  of  the 
lower  extremity  including  mensuration  and  comparison  with  the 
uninjured   member.     The   X-ray   is   invaluable   in   diagnosticating 


Fig.  600. — Drawing  a  line  lietween  tlie  anterior  superior  iliac  spine  and  the 
tuberosity  of  the  ischium  to  determine  the  relative  level  of  the  greater  tuberosity. 
Nelaton's  line.      (See  Fig.   587.) 

the  presence  of  fracture ;  in  fact  it  is  the  only  means  of  determining 
accurately  the  details  of  the  injury. 

Nelaton's  line  and  Bryant's  triangle  (see  Fig.  587),  should  be 
mapped  out  and  the  position  of  the  trochanter  determined  with 
relation  to  the  bony  landmarks  of  the  pelvis.  (See  ''Anatomy," 
page  533.)  The  case  should  be  carefully  inspected  for  the  purpose 
of  recognizing  deformity,  and  accurate  measurements  should  be 
made  before  manipulation  in  any  form  is  attempted.  The  distance 
from  the  anterior  superior  iliac  spine  to  the  tubercle  of  the  femur, 
and  then  to  the  internal  malleolus  should  be  taken  with  a  steel 
tape,  and  compared  with  the  distances  between  the  corresponding 
bony  prominences  of  the  opposite  lower  extremity.  In  taking  these 
measurements  the  patient  should  be  placed  squarely  in  bed  so  that 


540 


FRACTURES   AND   DISLOCATIONS 


a  line  (li'awii  through  the  aiitci'ior  su])('i'ior  iliac  spines  will  l)e  at 
I'iufht  aiigk'.s  to  the  .si)inal  coluiiiii.  In  other  words  the  pelvis  slioukl 
not  be  "tipped' "at  the  time  the  measurements  are  being  taken. 

Fracture  of  the  femoral  neck  must  be  differentiated  from  dislo- 
cations of  the  hip,  fi-aetui'e  of  the  aeetabuluiii  willi  oi-  without  dis- 


i. 


r:^ 


Fig.  601  and  602. — Mea.suring  the  length 
(if  the  Tower  e.xti'emity  from  the  anterior  supe- 
rior iliac  .^pine  to  the  tip  of  the  internal  mal- 
leolu.s.  The  legs  should  be  parallel  and  the 
pelvis  should  not  be  tipped.  In  other  words  a 
line  drawn  through  the  anterior  superior  iliac 
spines  should  be  at  riglit  angles  with  the 
median  plane  of  the  body.  (See  Pigs.  603 
and   604.) 

placement  of  the  head,  fracture  of 
the  pelvis,  and  fracture  of  the 
femoral  shaft. 

The  characteristic  attitude  as- 
sumed in  luxations  of  the  femoral 
head,  the  restricted  mobility  and, 
in  some  instances,  direct  palpation 
of  the  displaced  head,  should  serve 
to  distinguish  dislocations  of  the 
hip  from  fracture  of  the  femoral  neck.  In  fractures  of  the  fem- 
oral shaft  the  position  occupied  by  the  great  trochanter  will  be 
found  normal  and  the  point  of  preternatural  mobility  will  be  lo- 
cated below  it.  When  the  thigh  is  rotated  the  trochanter  will  fail 
to  follow  the  shaft.     Fracture  of  the  acetabular  ring  and  certain 


Fi^-.    I, 


FRACTURES   OP    UPPER   END   OF    FEMUR 


541 


pelvic  fractures  are  occasionally  difficult  to  differentiate  from 
fracture  of  the  femoral  neck  unless  a  Rontgenog:ram  is  made.  In 
fact  the  X-ray  should  be  emi)loyed  in  almost  all  injuries  about  the 


Fig.    603. 


Pig.    604. 


Fig.  603. — Measurements  of  the  lower  extremities  talcen  with  the  legs  parallel  and 
the  pelvis  up-tipped. 

Fig.  604. — Shows  the  effect  of  tipping  the  pelvis  when  these  measurements  are  being 
taken. 

hip.  Inspection,  palpation  and  mensuration  may  enable  one  to 
determine  the  seat  of  the  lesion  but  it  is  impossible  to  ascertain 
the  exact  details  and  nature  of  the  fracture  without  the  aid  of  an 
X-ray  plate.     Moreover  one  cannot  be  sure,  prior  to  examination, 


Fig.   605. — Picture  taken   lo   sliow  liow   the  fascia  lata  becomes  lax  between  the  iliac 
crest   and  the  trochanter  when   tlie  latter   is   raised  through   fracture   or   disease. 

whether  or  not  impaction  exists,  and  it  is  much  better  to  refrain 
from  manipulation  altogether,  rather  than  to  break  up  an  impac- 
tion.    The   surgeon  who  is  unaccustomed  to   dealing  Avith   these 


542  FRACTURES   AND   DISLOCATIONS 

cases  had  better  submit  the  patient  to  an  X-ray  examination  before 
any  extensive  manipuhitiou  is  attempted. 

Treatment. — Tlie  treatment  of  fracture  of  tlie  neck  of  the  fennir 
dei)ends,  first  on  the  age  and  conditiou  of  the  patient,  and  next  on 
wliether  or  not  the  fracture  is  impacted.  As  far  as  the  fracture 
itself  is  concerned,  recumbency  is  a  prime  requisite,  but  the  fact 
that  old  persons  are  unable  to  stand  prolonged  confinement  to  bed, 
makes  it  necessary  to  adopt  some  form  of  anibulatoi-y  treatment 
or  one  in  "which  the  patient  may  be  raised  to  the  sitting  position. 
AVhen  the  neek  of  tlie  fcmnr  is  fractured  in  elderly  persons  the 
treatment  is  often  more  a  question  of  the  prevention  of  compli- 
cations, such  as  hypostatic  pneumonia,  than  complete  restoration  of 
function  in  the  injured  member. 

There  are  at  the  present  time  four  recognized  methods  of  treat- 
ing fractures  of  the  hip.  They  are:  recunibency  luith  traction  and 
counter-traction,  the  plaster  cast,  the  ambulatory  splint  and  open 
treatment.  Each  form  of  treatment  has  its  modifications,  and  com- 
binations of  these  methods  are  not  uncommon  in  the  treatment  of 
fractures  of  the  femoral  neck.  None  of  them  is  ideal ;  they  all 
have  their  advantages  and  their  drawbacks.  Each  case  should  be 
carefully  considered  and  the  method  or  combinations  of  methods 
best  suited  to  the  case  in  hand  should  be  adopted.  In  selecting  the 
mode  of  procedure  to  be  followed  the  surgeon  must  consider  his 
surroundings  and  the  available  facilities  as  well  as  the  age  and 
condition  of  the  patient. 

If  the  patient  is  strong  enough  to  remain  in  bed  during  the 
process  of  repair  the  fracture  may  be  treated  by  Buck's  extension 
and  the  long  side  splint.  It  is  essential  that  the  bed  be  firm  and 
unsagging.  If  a  fracture  bed  cannot  be  obtained  tlie  ordinary  bed 
may  be  made  more  rigid  by  placing  boards  under  the  mattress  to 
prevent  sagging.  Buck's  extension  is  applied  as  shown  in  Figs. 
606  and  607.  The  lower  extremity  is  soaped,  shaved,  sponged 
with  alcohol  and  thoroughly  dried  before  the  adhesive  plaster 
is  applied.  The  wooden  spreader  below  the  foot  should  be 
broad  enough  to  keep  the  adhesive  plaster  from  touching  and 
irritating  the  ankles.  The  weights  employed  should  be  suffi- 
cient to  control  the  muscular  spasm  and  will  vary  with  the  build 
of  the  patient.  Greater  weight  will  be  required  during  the  first 
day  or  two  than  is  necessary  later  when  the  muscles  have  been  tired 
out  by  the  continuous  pull  of  the  extension  apparatus.     From  ten 


FRACTURES   OP    UPPER   END   OF    FRMIJR 


543 


V\iX.    GOr,. Sllnws 

on  the  lower   extreinily 


(llicsivc      lllMst.M-     lipiilicd 

Buck's   extt'iLsiuii. 


lo   secure   longitudinal   traction 


Pig.  607. — Shows  Buck's  extension  completed.  The  strips  of  adhesive  have  been 
fastened  to  the  spreader,  and  rope  puUey  and  weight  attached.  The  spreader  consists 
of  a  small  square  piece  of  light  board  with  a  hole  drilled  through  its  middle  for  the 
attachment  of  a  light  rope.  Its  purpose  is  to  prevent  the  adhesive  plaster  from  coming 
in  contact  with  the  skin  over  the  malleoli  and  to  act  as  an  equalizer  so  that  the  pull  will 
be  the  same  on  both  strips  of  adhesive.      (See  page  542.) 


bed, 


Fig.    608.  Fig.    609. 

Pig.   608. — A  convenient  form  of  weight  to  be  used  with  Buck's  extension. 

Fig,   gp9.— A   good   adaptation   of   the   pulley  to   be   attaehecl   to   the  foot  of   an  iron 


544 


FRACTFRES   AND   DISLOCATIONS 


to  twenty  poiiiuls  may  l)e  advisable  during  the  first  few  days,  but 
later  in  the  treatment  six  or  eight  pounds  will  usually  be  all  that 
is  necessary  tc  steady  tlie  i)arts  and  overeome  the  increased  mus- 
cular tone.  The  i)atient  will  be  more  comfortable  with  a  proper 
Aveio-ht  than  with  too  much  or  too  little.  Counter-extension  is  ob- 
tained by  raisinw  the  foot  of  the  bed  eight,  ten  or  even  fifteen 
inches,  according  to  the  weight  used.     AVith  the  extension  apparatus 


J- 


A 


Fig.    610. 


Fig.    611. 


Fig.  610. — Long  Tsplint  used  in  the  treatment  of  fractures  of  the  neck  or  shaft 
of  the  femur.  A  strip  of  wood  about  one  foot  in  length  may  be  nailed  in  the  angle 
of  the  splint  to  prevent  the  bed  clothes  resting  on  the  foot.  This  will  obviate  the  neces- 
sity of  using  a   cradle.      (See   Fig.   708.) 

Fig.  611. — A.  shows  Bucks  extension  applied  and  T-splint  in  position  with  appro- 
priate padding.  B.  shows  the  padding  bandaged  to  the  splint  and  the  latter  secured  in 
position  by  means  of  strips  of  adhesive  and  body  swathe. 


in  place  a  long  side  splint  is  applied,  the  upper  end  extends  to 
the  eighth  or  tenth  rib  and  is  secured  to  the  trunk  by  means  of  a 
body  swathe.  The  thigh  and  leg  are  secured  to  the  splint  by 
means  of  bandages  or  adhesive  plaster.  If  a  cross-piece  is  attached 
to  the  low'er  end  of  the  splint  it  will  render  the  whole  more  steady 
and  secure.  In  unimpacted  cases  particular  care  should  be  taken 
to  correct  eversion.  This  can  be  nicely  accomplished  by  transverse 
strips  of  adhesive  passing  under  the  thigh  and  over  the  side  splint 


FRACTURES    OF    UPPER   END    OK    FEMUR  545 

to  which  they  are  fastened.  If  the  fracture  is  impacted,  extension 
and  counter-extension  should  be  applied  with  caution  lest  the  im- 
paction be  broken  up.  Enough  weight,  however,  should  be  used 
to  control  the  muscular  spasm  which  is  capable,  in  some  cases,  of 
breaking  up  the  impaction,  if  not  counteracted  by  the  extension 
apparatus.  Sand  bags  on  either  side  of  the  limb  may  be  used  to 
advantage  instead  of  the  splint,  especially  in  impacted  cases.  Ex- 
tension and  counter-extension  is  one  of  the  oldest  methods  of  treat- 
ing fracture  of  the  hip.  The  fixation  secured  in  this  manner  is  not 
as  perfect  as  that  obtained  by  the  plaster  cast  or  by  one  of  the  metal 
splints  to  be  described  later ;  yet  excellent  results  have  followed  its 
use.  This  method  is  particularly  serviceable  during  the  first  week 
or  ten  days  following  the  accident.  It  is  often  advisable  to  substi- 
tute some  other  form  of  fixation  (such  as  the  brace  or  cast)  after 
the  acute  inflammatory  reaction  at  the  site  of  fracture  has  subsided, 
and  the  shortening  has  been  partially  or  completely  overcome  by 
the  extension  apparatus.  During  this  initial  period  one  can  de- 
termine by  palpation,  mensuration  and  the  X-ray  the  degree  of 
reduction  which  has  been  accomplished  by  non-operative  measures 
and  the  advisability  of  resorting  to  open  treatment. 

The  Ruth-Maxwell  method  is  an  elaboration  of  the  above  in  which 
lateral  traction  is  exerted  on  the  upjDcr  end  of  the  femur  in  addition 
to  longitudinal  extension  and  counter-extension.  The  longitudinal 
traction  is  accomplished  as  already  described.  The  outward  trac- 
tion on  the  upi^er  end  of  the  femur  is  had  by  means  of  a  sling 
passed  about  the  thigh  at  the  level  of  the  perineum,  and  then  by 
the  use  of  a  cord,  pulley  and  weight ;  outward  and  forward  traction 
is  exerted,  as  shown  in  Fig.  612.  Counter-extension  for  this  lateral 
traction  is  obtained  by  raising  the  same  side  of  the  bed  a  few 
inches.  In  unirapacted  cases  the  lateral  traction  may  be  made  to 
overcome  the  backward  displacement  of  the  upper  end  of  the  lower 
fragment.  E version  of  the  lower  extremity  can  be  corrected  by 
placing  most  of  the  pull  on  the  posterior  arm  of  the  sling  about 
the  thigh.  AVhen  used  in  this  way  the  sling  should  be  prevented 
from  slipping  about  the  thigh  by  securing  it  to  the  skin  with  ad- 
hesive. A  number  of  advantages  are  claimed  for  this  method: 
firstly,  that  the  neck  is  maintained  at  a  more  nearly  normal  angle 
during  the  process  of  repair,  secondly,  that  the  patient  may  be 
raised  to  the  sitting  position  without  disturbing  the  fragments,  and 
thirdly,  that  the  use  of  the  bed-pan  is  greatly  facilitated. 


546 


FRACTt'RES   AND   DISLOCATIONS 


The  advisability  of  employing  this  method  is  best  determined  in 
a  given  case,  by  ascertaining  the  degree  of  reduction  which  it  ac- 
complishes as  shown  by  palpation,  mensuration  and  the  X-ray.  If 
in  an  unimpaeted  case  the  apposition  is  improved  by  lateral  trac- 
tion, this  method  is  indicated. 

The  plaster  cast  has  been  used  with  considerable  satisfaction  and 
may  be  varied  to  meet  the  needs  of  the  case.  It  may  be  employed 
in  a  number  of  ways;  the  following  three  types  of  cast  will  be  found 
the  most  important. 

Tilt'   strai.uht   cast   is   most  often   employed    in    middle   aged   pa- 


\ 


Fig.    612. 


Fis.    613. 


Fis.  612. — Diagram  illustrating  the  principles  employed  in  the  treatment  of  frac- 
tures of  the  femoral  neck  according-  to  the  Ruth-Maxwell  method. 

Fig.  613. — Shows  the  proper  distribution  of  sand  bags  to  steady  the  lower  extremity 
when  the  hip  is  fractured. 

tients;  in  old  and  feeble  persons  the  cast  is  applied  with  the  knee 
and  hip  flexed  to  about  right  angles  so  that  the  patient  may  be 
raised  to  the  sitting  position  during  the  day ;  and  in  children  it 
may  be  applied  with  the  thigh  in  extreme  abduction  according  to 
the  principles  laid  down  by  Whitman. 

The  straight  cast  should  extend  from  the  waist  to  the  toes  and 
be  properly  lined  wdth  sheet  cotton  or  some  other  material,  to  avoid 
irritation  of  the  skin.  If  a  union  suit  of  soft,  ribbed  material  is 
put  on  before  the  cast  is  applied  we  will  have  a  very  satisfactory 
form  of  lining.  After  the  plaster  has  set  and  dried,  the  portion 
of  the  union  suit  not  covered  by  the  cast  may  be  cut  away.     A 


FRACTURES  OP  UPPER  END  OF  FEMUR 


547 


stomach  pad  should  be  placed  between  the  cast  and  the  abdomen 
the  same  as  employed  with  casts  of  the  trunk.  Special  recinforce- 
ments  of  plaster-soaked  gauze,  tin,  or  cypress  wood  should  be  used 
at  the  groin  and  behind  the  knee  where  the  cast  most  frequently 
breaks.  These  reenforcements  are  best  placed  between  the  different 
layers  of  the  plaster  bandages  as  the  cast  is  being  applied.  The 
knee  should  be  in  a  position  a  little  short  of  complete  extension  to 
avoid  subsequent  discomfort  in  the  joint.  The  cast  should  be 
heav.y  enough  to  stand  the  strain  of  the  six  or  eight  weeks  of  use 
to  which  it  will  be  put  during  the  after-treatment.     This  dressing 


Fig.  614, — Plaster  cast  for  fracture  of  the  hip  applied  witli  the  thigh  in  abduction. 
A  strap  passing  from  the  body  portion  of  the  cast  under  the  perineum  will  add  to  the 
security  of  the  fixation.  An  even  more  secure  form  of  cast  is  one  which  includes  both 
extremities   in   abduction. 

accomplishes  fixation  very  nicely  whether  recumbent  or  ambulatory 
treatment  is  employed.  If  used  as  an  ambulatory  splint  the  shoe 
of  the  opposite  foot  should  have  the  sole  built  up  as  is  commonly 
done  with  the  Thomas  splint.  The  ambulatory  treatment  should 
not  be  allowed  in  old  persons  unless  the  surgeon  is  satisfied  that  the 
patient  is  not  too  feeble  to  get  about  with  crutches  without  the  risk 
of  further  fall  and  injury.  Old  and  feeble  persons  do  not  stand 
confinement  in  bed  for  a  period  sufficient  to  obtain  union,  on  the 
other  hand  they  are  often  unable  to  get  about  with  the  added  en- 


548 


FKAt'TfUKS    AND    DlSl.OC'ATIOXS 


euinbrance  of  a  hip  splint  or  cast.     In  such  cases  the  author  has  had 
considerahlc  satisfaction  witli  the  followinij,-  original  luctliod. 

The  cdsl  is  appl'utl  icilli  IIk  hlji  (iikI  Ihc  knee  flexed  ul  about  right 
angles.  In  othei*  wortls  the  injurinl  nK'nil)er  is  encased  in  plaster 
in  the  attitude  noi'uudly  assumed  when  the  jiatient  is  seated.  Witli 
tlie  lower  t'xti'eunty  in  this  position  the  patient  can  coiiit'oi'tably 
occupy  an  easy  chair  dui'iug  the  day  and  still  rest  well  iu  bed  at 
night  with  the  tiexed  lower  exti'eniity  properly  bolstered.  If  a 
Morris  chair  is  employed  in  the  treatment,  the  iiio\ahle  l)ack  may 
be  raised  during  the  day  and  the  foot  of  tlie  injured  uicudjer  prop- 
erly supported  on  a  foot  stool  oi-  i)illows.      When  night  comes  the 


Fig.  615. — Ciist  of  lower  (■.\trcinit.\-  and  trunk  applied  witli  tlu'  tliijih  and_  le^ 
flexed  to  right  angles.  This  form  of  fast  is  of  gi-eat  advantage  when  the  hip  is  frac- 
tured in  elderly  persons  who  are  unable  to  stand  the  recumbent  position.  During  the 
day  the  patient  may  be  placed  in  the  sitting  position  while  at  night  he  may  lie  on  his 
back  with  the   injured   member  properly  bolstered.      (See   text.) 

back  of  the  chair  can  be  lowered  so  that  the  patient  resumes  the 
dorsal  recumbent  position,  while  the  injured  leg  is  raised  and  sup- 
ported by  pillows,  sand  bags  or  some  other  arrangement.  (See 
Fig.  615.)  In  this  way  he  may  enjoy  good  rest  at  night  and  still 
be  in  the  sitting  position  during  the  day,  thus  avoiding  the  develop- 
ment of  hypostatic  pneumonia.  If  traction  is  made  at  the  knee 
while  the  plaster  is  setting  a  fair  degree  of  extension  and  counter- 
extension  may  be  had  during  the  after-treatment.  This  is  made 
possible  by  the  position  of  the  leg  which  is  at  right  angles  Avith 
the  thigh. 

The  plaster  cast  man  ^i<^  employed  with  tlie  thigh  in  extreme  ab- 
duction as  practiced   hy   Whitinaii.     This   method   is   particularly 


FRACT[JRES    OF    UPl'ER    END    OP    KKMIJR  549 

applicable  in  children  and  is  based  on  sound  mechanical  and  ana- 
tomical principles.  By  abducting  the  thigh  the  lower  portion  of 
the  capsular  ligament  is  made  tense  and  the  fractured  surfaces  (if 
engaged  at  all)  are  thus  forced  firmly  together.  This  position  is 
maintained  by  means  of  a  plaster  of  Paris  spica  of  the  thigh.  In 
selected  cases  this  method  will  be  productive  of  excellent  results 
and  deserves  a  more  extended  trial  in  adults. 

It  should  never  be  taken  for  granted,  in  a  given  case,  that  good 
reduction  has  been  accomplished  because  the  thigh  has  been  ab- 
ducted and  fixed  in  this  attitude.  The  position  of  the  fragments 
should  be  verified  by  the  X-ray. 

The  reason  that  this  method  has  met  with  such  success  in  chil- 
dren is  due  firstly,  to  the  fact  that  fractures  of  the  femoral  neck 
at  this  period  of  life  are  seldom  complete,  and  secondly,  that  ab- 
duction with  the  fractured  surfaces  opposed  and  firmly  engaged 
tends  to  prevent  the  subsequent  lessening  of  the  angle  at  which 
the  neck  joins  the  shaft.  In  other  words,  it  prevents  coxa  vara. 
If  the  fractured  surfaces  are  not  engaged  this  method  is  valueless. 

The  Thomas  hip  splint  has  been  used  with  considerable  success 
by  some  surgeons.  The  main  drawback  to  this  splint,  and  others 
employing  the  same  materials  and  principles,  consists  in  the  cost 
and  the  difficulty  of  obtaining  the  services  of  some  one  competent 
to  properly  make  and  fit  it  to  the  patient  at  the  time  it  is  needed. 
The  surgeon  is  not,  as  a  rule,  equipped  for  this  work  which  should 
be  done  by  an  experienced  blacksmith  and  leather-worker.  In 
most  of  the  larger  cities  there  are  makers  of  surgical  instruments 
and  orthopedic  appliances  who  are  thoroughly  qualified  to  produce 
and  fit  a  satisfactory  splint,  but  in  country  practice  it  is  often 
difficult  to  procure  the  desired  apparatus  on  short  notice. 

The  splint  is  made  of  soft  iron  and  consists  of  a  main  stem  or 
bar  of  3/16  by  5/8  inch  material  which  extends  from  the  chest  to 
the  ankle  along  the  posterior  aspect  of  the  trunk  and  lower  extrem- 
ity. To  this  main  stem  is  attached  a  chest-band,  a  thigh-band  and 
a  calf -band  as  indicated  in  the  accompanying  diagram  (Fig.  620). 
These  bands  are  made  of  strips  of  soft  iron  %  by  one  inch,  on 
cross  section,  and  are  bent  into  position  when  the  splint  is  applied. 
Different  weights  of  material  may  be  used  according  to  the  size 
and  musculature  of  the  patient,  and  the  transverse  encircling  bands 
may  be  varied  in  position  and  number  according  to  the  nature  of 
the  case  and  the  fixation  desired.     The  main  stem  of  the  splint 


550  FRArTTRES    AND    DTSLOCATTONS 

should  follow  tho  c-urvt's  of  tlif  Wndy  mid  lower  extremity,  and  the 
points  of  juiH'tion  between  main  slem  and  bands  should  be  Hush, 
to  avoid  nndu.e  local  pressui-e  and  irritation.  The  entire  splint 
should  be  well  i)added  and  ])ound  with  leather  and  the  anterior 
extremities  of  the  horizontal  bands  connected  by  straps  and  buckles. 
By  means  of  crutches  and  a  built-up  shoe  for  the  opposite  foot  the 
l)atient,  after  some  practice,  is  able  to  be  up  and  aljnut.  It  often 
recpiires  a  number  of  trials  before  he  becomes  sufficiently  sure- 
footed under  these  awkward  circumstances,  and  the  surgeon  should 
see  that  he  is  properly  attended  to  prevent  falling. 

When  ambulatory  treatment  is  indicated,  as  is  the  case  in  old 
persons  from  the  first,  and  in  younger  patients  during  the  second 
half  of  the  after-treatment,  the  Thomas  splint  has  served  well.  If 
extension  is  required  it  may  be  had  by  means  of  adhesive  strips 
applied  in  a  manner  similar  to  that  shown  in  the  use  of  Buck's 
extension  (see  page  543).  The  low-er  ends  of  the  longitudinal 
strij)s  of  adhesive  are  secured,  under  tension,  to  the  calf  bands  of 
the  splint. 


Fig.    616. — Authors    screw    plates    iur    internal    fixation    of    fractures    of    the    femoral 
neck.      (See  Figs.   617,   618   and  619.) 

The  ambulatory  pneumatic  splint,  as  shown  in  Fig.  621,  with 
the  hip  attachment,  has  the  advantage  of  being  adjustable,  so  that 
it  can  1)6  used  on  ditferent  cases,  and  is  so  constructed  that  it  may 
be  used  for  either  hip.  Extension  is  also  provided  for  when  needed 
(see  Fig.  719). 

Operative  Treatment. — The  open  method  is  indicated  in  non- 
impacted  cases  in  which  the  fragments  cannot  otherwise  be  brought 
back  into  satisfactory  apposition.  Nailing  and  pegging  the  neck 
in  place  have  been  practiced  for  some  years  past  but,  because  of 
the  internal  structure  of  the  upper  end  of  the  femur,  the  end  re- 
sults have  not  been  as  encouraging  as  might  be  desired.  The 
cancellous  tissue,  through  wdiicli  the  screw  passes,  crushes  so  readily 
that  displacement  following  the  operation  is  prone  to  occur.     The 


FRACTURES   OF    UPPER   END   OF   FEMUR 


551 


manner  in  which  this  takes  place  is  indicated  in  Fig.  618.  To 
avoid  this  result  two  screws  or  nails,  placed  at  different  angles  have 
been  used  but  the  results  following  this  method  have  been  almost 
as  uniformly  inefficient  as  when  a  single  screw  is  employed.  A 
much  more  satisfactory  method  is  that  devised  by  the  author  in 


Fig.    619. 

Fig.  617. — Diagram  of  femur  showing  the  common  sites  of  fracture  of  the  femoral 
neclj.      {Surg.,  Oynecol.  and  Ohstet.,  Feb.  1914.) 

Fig.  613. — Diagram  showing  the  manner  in  which  the  cancellous  tissue  crushes  wlien 
the  neck  is  subjected  to  the  displacing  action  of  the  thigh  and  hip  muscles,  following 
operation  with  a  simple  screw  or  nail.      (Surg.,  Gynecol,  and  Obstet.,  Feb.,   1914.) 

Fig.  619. — Diagram  showing  the  author's  screw-plate  in  position.  Angulation  of 
the  screw  portion  is  prevented  by  the  plate  portion  which  secures  a  firm  hold  on  the  only 
available  compact  tissue  in  this  region.      (Surg.,  Gynecol,  and  Obstet.,  Feb.,    1914.) 

which  a  modified  Lane  plate  is  employed,  as  shown  in  Fig.  619. 
By  means  of  this  screw-plate  the  compact  tissue  below  the  great 
trochanter  is  utilized  to  prevent  the  inner  end  of  the  screw  portion 
of  the  appliance  from  being  displaced  downward.  The  head  of  the 
bone  is  thus  hung  on  the  end  of  the  screw  portion  much  as  a  hat 
is  hung  on  a  peg,  the  plate  securing  its  hold  on  compact  tissue. 


552  FRACTURES   AND   DISLOCATIONS 

Before  drilliiiir  tlirony:li  the  troeliauter  the  surgeon  should  make 
sure  of  the  i)roper  alignment  of  the  liead  and  neek.  This  can 
usually  be  accomplished  by  dull  dissection  along  the  neck  outside 
the  oai>sule.  Following  operation,  external  fixation  apparatus 
sliould  be  employed  to  relieve  the  bone  of  as  nuieh  strain  as  pos- 
sible. Simple  extension  and  counter-extension  with  the  long  side 
splint  may  be  used,  or  the  i)laster  east  applied.  The  east  is,  as  a 
rule,  preferable  following  operation  on  the  hip  or  thigh  and  should 
be  applied  before  the  patient  comes  out  of  the  anesthetic.  Within 
forty-eight  hours  of  the  operation  a  window  should  be  cut  thi-ough 
the  plaster  to  expose  the  region  of  incision.  In  operating  on  the 
neck  of  the  femur  the  parts  may  be  exposed  by  a  vertical  incision 
over  the  trochanter  or  an  incision  of  the  U-type  may  be  employed. 

The  best  time  for  operation  is  at  the  end  of  a  week  or  ten  daj^s 
following  the  accident.  When  the  open  method  is  selected  early 
in  the  condition  because  it  offers  better  reduction  and  apposition 
of  the  fractured  surfaces  the  results  are  usually  satisfactory. 
When,  however,  operation  is  performed  as  a  last  resort  when  other 
methods  have  resulted  in  non-union  or  deformity  the  results  are 
not  nearly  as  good.  In  operating  for  non-union  the  fibrous  tissue 
must  be  cut  away  and  the  fractured  surfaces  freshened  and  secured 
in  apposition,  preferably  by  the  screw-plate  just  described.  This 
procedure  necessarily  results  in  some  loss  of  tissue  and  shortening 
of  the  neek.  If  the  fracture  is  through  the  inner  end  of  the  neck, 
and  the  head  is  comminuted,  it  may  be  advisable  to  remove  the 
fragments,  round  off  the  end  of  the  femoral  neck  and  rely  on  the 
formation  of  a  new  articular  surface.  Remarkably  good  results 
have  followed  resection  of  the  femoral  head.  IMurphy  has  demon- 
strated the  possibility  of  making  a  new  femoral  head  and  articular 
surface  from  a  transplanted  portion  of  the  great  trochanter,  and 
of  reestablishing  the  function  of  the  joint  following  ankylosis. 
These  operations,  however,  are  rarely  called  for  as  a  result  of  frac- 
ture of  the  femoral  neck.  Operative  intervention  offers  little  in 
the  aged  and  is  seldom  called  for  in  children.  It  offers  most  in 
the  healthy  adult,  and  is  indicated  in  cases  in  which  good  reduction 
cannot  otherwise  be  obtained,  and  in  instances  in  which  deformity 
or  non-union  with  considerable  loss  of  function  has  followed  non- 
operative  methods. 

After-Treatment. — The  fact  that  the  fragments  have  been  placed 
in  good  apposition  does  not  necessarily  mean  tliat  they  wdll  remain 


FRACTURES  OP  UPPER  END  OP  FEMUR 


553 


so  and  it  should  be  the  surgeon's  greatest  care  during  the  after- 
treatment  to  see  that  the  fixation  apparatus  employed  is  properly 
performing  its  function.  Numerous  adjustments  will  be  needed 
during  the  process  of  repair.  A  weight  of  fifteen  or  twenty  pounds 
may  be  necessary  during  the  first  few  days  but  at  the  end  of  a 
week  it  may  be  entirely  too  much.  If  the  patient  is  confined  to 
bed  the  back  and  heels  should  be  watched  for  signs  of  skin  irrita- 
tion, and  should  they  develop  special  care  must  be  taken  to  keep 
the  parts  dry  and  relieved  of  pressure.  The  sheets  should  be  clean, 
smooth  and  free  from  wrinkles  and  the  patient  should  be  frequently 


Fig.   620. — Diagrams  illustrating  the  principles  of  the  single  and  double  Thomas  hip 
splint. 

sponged  and  rubbed  with  alcohol  especially  in  regions  subjected  to 
pressure.  If  a  metal  splint  or  cast  is  used  the  points  of  pressure 
should  be  similarly  watched  and  treated  if  irritation  develops.  If 
the  cast  is  employed  it  may  be  necessary  to  cut  a  window  in  it,  if 
the  patient  complains  of  persistent  cutaneous  pain  in  a  given  region. 
The  duration  of  the  after-treatment  depends  on  the  progress  of 
repair  at  the  seat  of  fracture.  It  may  be  impossible  to  secure  bony 
union  in  the  aged  and  fixation  may,  in  some  cases,  be  prolonged 
indefinitely  without  result.  In  this  type  of  case  it  is  better  to  get 
the  patient  up  and  about  after  sufficient  time  has  elapsed  to  give 
the  fragments  a  fair  chance  to  unite.     Function  will,  of  course,  be 


554  FRACTURES   AND   DISLOCATIONS 

imperfect  but  the  i^atieiit  will  be  better  olf  than  if  a  prolonged, 
futile  immobilization  is  carried  out.  The  older  the  patient  the  less 
the  probability  of  bony  union  and  the  slower  it  will  be  in  forming, 
if  it  does  occur.  In  ;i  middle  aged  person  union  should  be  well 
advanced  at  the  cutl  of  cii^ht  or  ten  weeks  but  no  wcij^fht  should  be 


Fig.    621. — "The    Ambulatory    Pneumatic    Splint''    with    hip    attachment. 

borne  on  the  injured  member  inside  of  thi-ee  months.  During  the 
first  eight  weeks  the  hip  should  be  immobilized,  after  this  period 
gentle  passive  motion  is  advisable  up  to  the  third  mouth,  though 
all  strain  should  be  guarded  against.  Because  of  the  varying 
rapidity  in  the  process  of  repair  seen  at  different  ages  and  the 
different  types  of  fracture  encountered,  no  hard  and  fast  rule  can 


FRACTURES   OF    UPPER   END   OF    FEMUR  555 

be  laid  down  regarding  the  length  of  fixation.  ""I'lie  most  reliable 
information  concerning  the  progress  of  union  is  to  be  obtained 
through  the  X-ray.  Rontgenograms  taken  at  the  end  of,  say,  eight, 
ten,  and  twelve  weeks  will  show  the  condition  of  the  fragments 
and  the  progress  of  repair,  and  will  constitute  the  very  best  guide 
in  the  resumption  of  function.  The  patient's  comfort  during  the 
after-treatment  deserves  much  consideration,  especially  in  elderly 
persons.  The  surroundings  should  be  as  bright  and  cheerful  as 
possible.  His  friends  should  visit  him  frequently  but  should  not 
be  encouraged  to  stay  long  enough  to  weary  him. 

Prognosis. — Fracture  of  the  neck  of  the  femur  is  a  serious  injury 
even  under  the  most  favorable  circumstances.  In  the  aged  it  is 
particularly  dangerous  because  of  the  low  vitality  of  the  patient. 
They  not  infrequently  suffer  greatly  from  shock  and  confinement 
and  are  subject  to  complications  which,  in  their  asthenic  state,  may 
produce  death.  Bony  union  has  for  years  been  considered  as  de- 
pendent on  whether  or  not  the  fracture  was  within  the  joint  cavity. 
The  correct  conditions,  however,  are  probably  whether  or  not  the 
fractured  surfaces  are  in  firm  apposition. 

Under  proper  treatment  union  is  to  be  expected  in  a  healthy 
adult  but  in  the  aged  it  may  or  may  not  be  obtained  regardless  of 
the  treatment  folloAved.  Fibrous  union  means  some  impairment  of 
function,  yet  a  surprisingly  useful  hip  may  result  even  when  there 
has  been  failure  in  bony  union  and  some  deformity  exists. 

The  surgeon,  should  never,  even  under  seemingly  favorable  cir- 
cumstances, promise  bony  union. 

Injuries  to  the  Femoral  Neck  in  Children. — The  epiphysis  of 
the  head  joins  the  neck  at  about  the  eighteenth  year,  and  the  bony 
tissue  of  the  neck  is  tougher  and  less  brittle  than  in  adult  or  ad- 
vanced life.  These  anatomical  variations  account  for  the  clinical 
picture  accompanying  injury  of  the  femoral  neck  in  childhood.  A 
green-stick  fracture  of  the  neck  of  the  femur  or  an  epiphyseal  sepa- 
ration of  the  head  of  the  bone  (incomplete  as  it  usually  is)  is 
pathologically  and  mechanically  quite  different  from  fracture  of 
the  femoral  neck  as  seen  in  the  adult  or  the  patient  advanced  in 
years.  Accordingly  the  symptoms  and  course  of  the  ease  are  dif- 
ferent. In  an  incomplete  fracture  of  the  femoral  neck  the  head  of 
the  bone  is  depressed  and  the  neck  approaches  more  nearly  a  right 
angle.  This  change  in  the  angle  of  the  neck  increases  the  strain 
on  it  and  further  bending  of  the  neck  follows  unless  all  weight- 


556  FRACTURES   AND   DISLOCATIONS 

beariiijr,  jar  and  strain  are  removed.  In  "starting"  of  the  ep- 
iphysis the  pathology  is  somewhat  dift'erent,  though  the  result  is 
practically  the. same.  "When  the  epiphysis  is  ''started"  it  is  dis- 
placed downward,  and  the  fractured  surface  is  only  partially  con- 
tacted with  the  end  of  the  diaphysis.  This  downward  displacement 
of  the  head  is  equivalent  to  a  downward  bending  of  the  neck  seen  in 
green-stick  fractures  of  tlie  neck,  and  if  the  patient  continues  to  use 
the  member  the  result  will  be  the  same ;  namely  coxa  vara.  Either 
of  these  injuries  usually  follows  severe  trauma  and  after  being  con- 
fined for  a  short  time  in  bed  the  patient  is  up  and  about  although 
limping.  The  limp  is  thought  little  of  at  fii-st,  but  when  this 
symptom  increases  instead  of  improving  the  surgeon's  advice  is 
sought.     In   some    instances    apparent    immediate    recovery    takes 


Fig:.  622. — Diagrams  to  illustrate  the  development  of  coxa  vara  in  a  child  following 
an  injury  to  the  hip  in  which  the  epiphysis  is  "started."  A.,  normal  hip  in  child  about 
four  years  old.  B..  same  after  injury  which  has  startetl  the  epiphysis  of  the  head  and 
allows  the  trochanter  to  be  displaced  upward.  C.  change  in  angle  of  neck  resulting 
from  the  altered  position  of  the  head.  7?.,  further  change  in  the  angle  of  the  neck  and 
raising  of  the  trochanter,  which  result  from  the  increased  strain  on  the  neck  of  the 
femur  as  it  approaches  the  right  angle.  The  elevation  of  the  trochanter  limits  abduction 
by  mechanical  interference  between  the  trochanter  and  the  rim  of  the  acetabulum. 
(After  Whitman.) 

place,  and  months  or  even  years  later  coxa  vara  develops  with  pro- 
gressive bending  of  the  femoral  neck  and  corresponding  impairment 
of  function.  The  immediate  symptoms  are  slight,  as  a  rule,  and  the 
condition  may  go  unrecogTiized  by  the  surgeon  as  well  as  the  family. 
The  apparent  insignificance  of  the  initial  injury  and  the  disastrous 
late  consequences  point  out  the  necessity  of  the  most  careful  ex- 
amination following  injuries  of  the  hip  in  children.  If  the  lower 
extremities  are  carefully  measured  it  will  usually  be  found  that  the 
injured  member  is  from  one  half  to  one  inch  shorter  than  its  fellow, 
and  there  may  be  slight  eversion  of  the  thigli.  The  X-ray  should  be 
employed  when  there  is  a  historv'  of  injury  to  the  hip,  even  if  only 
for  the  purpose  of  exclusion. 

If  the  case  is  seen  soon  after  the  initial  injury  it  should  be  treated 
by  rest  in  bed  \rith  Buck's  extension  applied  and  sand  bags  about  the 


FRACTURES   OP    UPPER   END   OP   PEMUR  557 

injured  member,  or  the  long  side  splint  employed.  Tf  deformity 
exists  after  the  acute  traumatic  stage  has  passed  the  plaster  cast 
should  be  employed  with  the  lower  extremity  in  abduction  accord- 
ing to  the  principles  laid  down  by  Whitman.  (See  Fig.  614.)  At 
the  end  of  a  month  this  dressing  may  be  replaced  by  an  ambulatory' 
hip  splint  with  traction  which  is  to  be  worn  for  a  number  of  months, 
until  union  is  solid  and  the  danger  of  coxa  vara  passed.  After  this 
splint  is  removed  the  hip  should  be  frequently  examined  by  the 
X-ray  to  determine  whether  the  strain  incurred  by  use  of  the  mem- 
ber is  causing  any  change  in  the  angle  of  the  neck.  If  such  is 
found  to  be  the  case  the  splint  should  be  resumed  with  increased 
traction.  If  the  case  is  seen  only  after  the  development  of  the 
secondary  symptoms  and  coxa  vara  is  present  the  traction  am- 
bulatory splint  should  be  employed  and  worn  for  a  number  of 
months.  If  the  deformity  and  disturbance  in  function  are  pro- 
nounced it  is  well  to  consider  the  advisability  of  an  osteotomy  to 
restore  the  angle  of  the  neck. 


CHAPTER  XXXVIII. 

FRACTURES  OF  THE  FEIMORAL  SHAFT. 

Surgical  Anatomy. — The  shaft  of  tlie  femur  consists  of  a  tube 
of  heavy  compact  tissue  which  is  capable  of  withstanding  greater 
strain  than  the  shafts  of  other  long  bones.  The  diameter  of  the 
shaft  grows  larger  and  the  compact  tissue  thinner  as  the  extremi- 
ties are  approached.  Ossification  spreads  from  a  single  center 
which  makes  its  appearance  about  the  seventh  week  of  foetal  life. 
The  shaft  is  slightly  curved  with  the  concavity  backward.  The 
linea  aspera  serves  to  strengthen  the  concave  posterior  aspect  and 
affords  attachment  to  the  adductor  muscles.  In  the  upper  third  of 
the  shaft  this  line  divides  into  three  ridges,  while  in  the  lower 
third  of  the  bone  it  bifurcates  to  form  the  supracondylar  ridges. 
The  femoral  vessels  cross  the  internal  supracondylar  ridge  under  a 
fibrous  arch  in  the  adductor  magnus  and  become  the  popliteal  ves- 
sels. From  the  point  where  the  artery  pierces  the  adductor  mag- 
nus to  the  knee  joint,  it  lies  in  close  relation  to  the  posterior  surface 
of  the  bone,  and  in  fractures  of  this  region  the  vessel  may  be 
injured  by  a  displaced  fragment.  The  nerve  and  vein  lie  more 
superficially  in  the  popliteal  space  and  are  less  subject  to  injury 
from  the  bone,  than  is  the  artery.  The  greater  part  of  the  three 
surfaces  of  the  femoral  shaft  are  taken  up  by  the  attachments  of 
the  three  vasti  muscles  which,  together  with  the  rectus,  make  up 
the  quadriceps  extensor.  Fracture  of  the  shaft  of  the  femur  is 
usually  attended  by  great  shortening,  which  results  from  the  con- 
traction of  the  powerful  thigh  muscles.  The  manner  in  which  the 
fragments  override  will  depend  largely  on  the  direction  and  nature 
of  the  break.  In  fractures  of  the  upper  third  of  the  shaft,  it  is 
common  to  see  the  upper  fragment  displaced  outward  or  outward 
and  forward,  while  the  lower  fragment  is  drawn  upward  by  the 
thigh  muscles  and  displaced  inward  by  the  action  of  the  adductor 
group.  Outward  rotation  of  the  upper  fragment  not  infrequently 
results  from  the  pull  of  tlie  ilio-psoas.  A  transverse  fracture  with 
the  serrated  surfaces  engaged  will,  of  course,  allow  only  of  angular 

558 


FRACTURES    OP    THE    FEMORATi    STfAKT 


559 


deformity  as  long  as  the  fraetnred  surfaces  remain  locked,  but  this 
condition  is  rare.     Fractures  in  tl)e  lower  third  of  the  shaft  are 


Fig.    623 


Figs.  623  and  624. — Anterior  and  posterior  surfaces  of  tlie  right  femur  with  at- 
tached muscles.  Ob.  d  G.,  Obturator  internus  and  gemelli ;  P.,  Pyriformis;  G.Min., 
Gluteus  minimus;  Y.E.,  Vastus  externus ;  G.Med.,  Gluteus  medius :"  Q.F.,  Quadratus 
femoris;  Ps.,  Psoas;  Pe..  Pectineus;  /.,  Iliacus;  A.B.,  Adductor  brevis ;  A.M.,  Adductor 
magnus;  V.I.,  Vastus  internus;  A.L.,  Adductor  longus ;  0.,  Crureus  or  Vastus  inter- 
medins;  Bic,  Biceps;   S.C.,  Subcrureus ;   (?.,   Gastrocnemius;   PL,  Plantaris. 

often  accompanied  by  a  backward  displacement  of  the  lower  frag- 
ment as  a  result  of  the  action  of  the  gastrocnemius,  the  two  heads 
of  which  are  attached  just  above  the  condyles  on  the  posterior 


560  FRACTURES   AND   DISLOCATIONS 

aspect  of  tlio  bone.  The  powerful  action  of  the  thi^rh  muscles 
usually  results  in  pronounced  deforniit}^  and  their  l)ulk  renders 
jialpation  diflficult. 

Etiology.— Fractures  of  the  femoral  shaft  constitute  less  than 
thiee  jxreent  of  all  fractures.  Approximately  one-fifth  of  the 
fractures  of  the  femoral  shaft  occur  in  the  upper  third  (not  in- 
elu(lin?T  the  femoral  neck),  three-fiftlis  occur  in  tlie  middle  third 


Fig.    625. — Traiisvt'i-se  fracture  ui  the  &hall  ul  the  I'ciiuir  witli  uverriding  and  angular 
deformity. 

of  the  bone,  while  one-fifth  is  seen  in  the  lower  end.  Fracture  of 
the  femoral  shaft  is  the  result  of  violence,  direct  and  indirect  and 
of  muscular  action,  although  the  latter  cause  is  probablj^  never 
responsible  for  fracture  in  a  healthy  bone.  Twisting  strains  fre- 
quently produce  the  spiral  or  oblique  fracture  so  commonly  seen 
in  the  upper  and  middle  thirds  of  the  shaft,  while  direct  violence 
more  often  results  in  transverse  fracture  of  the  lower  third.     All 


FRACTURES   OF   THE   FEMORAL   SHAFT 


561 


types  of  fracture,  however,   may   be  seen  in   any   portion   of  the 
shaft. 

Symptoms. — Immediate  and  total  loss  of  function  is  seen  fol- 
lowing the  accident,  except  in  the  green-stick  type  occurring  in 
children.  Pain  is  usually  pronounced  and  the  deformity  is  char- 
acteristic.    The  limb  below  the  break  is  rolled,  either  inward  or 


Fig.  626. — Fracture  of  right  femur  about  twenty  minutes  after  injury.  Fracture 
caused  by  patient  falling  from  first  floor  fire  escape  to  the  sidewalli.  Violence  trans- 
mitted through  foot  and  leg.  Note  the  shortening  of  the  limb,  the  eversion  of  the  foot 
and  knee  and  the  twisting  of  the  muscles  of  the  thigh. 


Fig.  627. — Case  similar  to  the  preceding  about  three  and  one-half  months  after 
injury.  Fibrous  union,  deformity,  loss  of  function.  Fracture  slightly  oblique  and  about 
four  inches  below  the  great  trochanter.  Note  the  eversion,  shortening,  and  wasting  of 
the  thigh  muscles.  Upper  end  of  lower  fragment  is  in  contact  with  the  lower  surface 
of  the  femoral  neck  and  united  to  it  by  fibrous  tissue.  Upper  fragment  abducted.  Case 
operated.  Incision  on  outer  side  of  thigh,  dense  fibrous  tissue  broken  up,  ends  of  bone 
squared  and  wired  together,  most  of  the  shortening  and  all  of  the  eversion  corrected. 
Function  restored.      Case  first  seen  by   author  three  and   a  half  months   after  injury. 


outward  (usually  the  latter),  and  the  helplessness  of  the  condition 
is  typical.  There  is  often  considerable  swelling  at  the  site  of  frac- 
ture and  in  addition  the  thigh  is  actually  thickened  as  a  result  of 
the  overriding  fragments  and  shortened  muscles.  The  thigh  is 
shortened  according  to  the  distance  the  fragments  have  overridden. 
The  decrease  in  the  length  of  the  thigh  can,  as  a  rule,  be  recognized 


562 


FRACTURES   AND   DISLOCATIONS 


witliont  tlie  aid  of  the  stool  tape.  Pain  is  greatly  increased  on 
manipulation.  Abnormal  mobility  can  nsnally  be  recognized  as 
soon  as  the  lower  extremity  is  grasped  and  moved.  Crepitus  may 
be  elicited  if  the  fractured  surfaces  are  in  contact.  The  symptoms 
are,  as  a  rule,  ])i'onounccd  and  tlio  shock  coiisi(l(M-able.  Spasm  of 
the  tliigh   muscles  is  pi-eseiit  and  the  result ing  slioi'lening  usually 


Fig.  628. — Fracture  of  left  femur  about  one  hour  following  injury.  Lower  end  of 
upper  fragment  produces  the  prominence  on  the  outer  aspect  of  the  thigh  as  indicated 
by  the  arrow.  Patient  assumes  this  position  as  a  matter  of  choice.  Leg  much  slu)rt- 
ened  though  this  is  difficult  to   determine   in  the  picture  as  the  opposite  thigh   is   fle.xed. 


Fig.  629. — Fracture  of  the  shaft  of  the  femur  at  point  indicated  by  arrow.  Pro- 
nounced shortening  with  thickening  of  thigh  at  seat  of  fracture  as  a  result  of  over- 
riding of  fragments.  Complete  eversion  below  break.  Flail-like  condition  recognized 
when  the  limb  is  manipulated.  Upper  fragment  displaced  anteriorly.  Photograph  taken 
■within  twenty  minutes   of   injury. 


increases  during  the  first  twent^'-four  or  forty-eight  hours,  unless 
special  preventive  measures  are  employed  in  the  treatment. 
Green-stick  fracture  sometimes  occurs  in  children.  In  the  pres- 
ence of  this  condition  the  s.ymptoms  will  be  less  pronounced,  bowing 
of  the  femur  will  usually  be  apparent  and  lateral  pressure  on  the 
thigh,  in  the  direction  of  the  bowing,  will  show  an  increased  spring 
in  the  bone  as  compared  with  the  uninjured  femur. 

Diagnosis. — There  is  seldom  any  difficulty  in  recognizing  fracture 
of  the  femoral  shaft.  The  deformity,  shortening,  loss  of  function, 
abnormal  mobility  and  crepitus  render  the  diagnosis  easy.  The 
exact  nature  and  position  of  the  fracture,  however,  can  only  be 


FRACTURES   OP    THE   FEMORAL   SHAFT  563 

learned  by  means  of  the  X-ray  or  during  opei-ation  when  the  frag- 
ments are  exjjosed.  Even  under  anestliesia,  |)ali)ation  and  jrianip- 
ulation  aliord  only  an  imperfect  knowledge  of  the  nature  of  the 
fracture.  Fracture  of  the  upper  end  of  the  femoral  shaft  miglit 
be  confounded  with  fracture  of  the  femoral  neck,  fracture  of  th(; 
rim  of  the  acetabulum  or  fracture  of  the  pelvis.  The  unaltered 
position  of  the  great  trochanter,  its  normal  relation  with  Nelatoii  's 
line  (see  page  533)  and  the  fact  that  it  fails  to  rotate  with  the  sliaft, 
will  serve  to  differentiate  fracture  of  the  femoral  shaft  from  the 
conditions  just  enumerated.  Fracture  of  the  shaft  of  the  femur  in 
the  new-born  is  devoid  of  subjective  symptoms  and  must  be  recog- 
nized by  the  physical  signs. 

The  less  the  thigh  is  manipulated  the  better :  nearly  all  that  can 
be  learned  by  physical  examination  can  be  gathered  by  inspection 
alone,  if  the  surgeon  is  observant.  The  deformity,  helpless  attitude 
of  the  limb,  shortening,  etc.,  and  the  history  of  the  case  should  be 
sufficient  evidence  of  the  presence  of  fracture  and  its  approximate 
location.  Abnormal  mobility  and  crepitus  manifest  themselves 
while  the  limb  is  being  brought  back  into  alignment  incident  to  the 
application  of  Buck's  extension  and  splints. 

If  doubt  exists,  careful  measurements  of  the  two  lower  extrem- 
ities should  be  made  and  the  same  precautions  are  to  be  observed 
as  already  cited  in  fracture  of  the  neck  of  the  femur  (page  539). 
The  patient  should  lie  straight  in  bed  so  that  a  line  drawn  through 
the  two  antero-superior  iliac  spines  is  at  right  angles  to  the  median 
plane  of  the  body  and  the  lower  extremities  should  be  parallel. 
The  usual  deformity,  however,  with  the  lower  extremity  rolled  out- 
ward, the  thigh  thickened  and  shortened  and  often  angular  dis- 
placement present,  is,  as  a  rule,  too  pronounced  to  require  mensura- 
tion to  establish  a  diagnosis.  Moreover  it  will  be  most  unwise  to 
manipulate  the  thigh  to  bring  it  to  a  position  which  is  parallel  or 
symmetrical  to  its  fellow,  simply  for  the  purpose  of  mensuration 
when  the  condition  is  already  apparent  through  inspection  alone. 

Treatment. — The  treatment  of  fracture  of  the  femoral  shaft  varies 
with  the  age  and  condition  of  the  patient  and  the  nature  and 
position  of  the  fracture.  The  emergency  treatment  and  the  care 
of  the  case  during  the  first  week  are  practically  the  same  in  all 
instances  and  will  be  considered  first. 

The  emergency  treatment  of  these  fractures  is  of  importance 
in  transporting  the   case  from  the  scene   of  the   accident   to   the 


564 


FRACTURES   AND    DISLOCATIONS 


hospital  or  lioinc.  llospilnl  facilities  and  suri'onndiiigs  are  of  the 
greatest  ndx'antiiL;!'  in  the  |)i'()i)er  treatnu'iit  oL'  fractures  oi'  the  thigh 
aud  the  pnliciit  slidiild  I n ■  ;ul\ised  of  this  fact  at  the  earliest  possible 
monicnl.      Ill  1  raiispdi'l  iii^  1lic  patient  tlic  tln^li  and  leg  should  be 


Fig.  C30. — Diagram  illustrating  the  manner  in  which  lateral  traction  may  be  applied 
to  bring  the  fragments  into  better  position.  Tlie  appliances  used  in  the  treatment  of 
fractures  of  the  femoral  shaft  are  similar  to  those  employed  in  the  treatment  of  frac- 
tures of  the  upper  end  of  this  bone.      (See  Figs.   606  to   612.) 

supported  by  some  form  of  temporary  splint  to  prevent  further 
laceration  of  the  soft  tissues  by  the  fragments.  This  may  be  accom- 
plished by  means  of  a  bed  slat  or  some  other  similar  piece  of  wood 


Fig.  G31. — .\d,iust.il)h'  inclined  jilane  \ised  in  the  treatment  of  certain  fractures  of 
the  femur.  For  otlier  metliods  of  fixing  the  thigh  in  various  degrees  of  flexion  see  Figs. 
615,   632,    633,   650,   65],   652,   653,   654   and   706. 

which  is  bound  or  strapped  to  the  lower  extremity  and  trunk  on 
the  injured  side.  A  blanket,  sheet  or  towels  may  be  used  to  secure 
the  .splint  in  position.  A  short  splint  on  the  inner  side  of  the  thigh 
will  increase  the  security  of  the  dressing.     A  satisfactory  emergency 


FRACTURES   OF   THE   FEMORAL   SHAFT 


565 


splint  may  be  made  with  })roomsticks  and  a  blanket.  In  moving 
the  patient  to  or  from  tlie  stretcher  one;  person  should  confine  his 
entire  attention  to  the  injured  member  to  prevent  motion  between 
the  fragments,  wliile  assistants  raise  and  move  hiin.     As  soon  as 


Figs.  632  and  633. — Showing  the  method  of  treating  fracture  of  the  shaft  of  the 
feniur  in  children  by  vertical  extension.  At  the  end  of  two  weeks  the  extremity  is  low- 
ered to  an  inclined  plane  and  treated  in  this  position  imtil  union  is  complete.  "  The  pa- 
tient IS  secured  to  a  Bradford  frame  by  means  of  a  band  about  the  body. 


Fig.  634. — The  Bradford  frame.  The  frame  is  made  of  gas  pipe  and  covered  with 
canvas  It  is  usually  necessary  to  employ  some  means  of  securing  the  patient  (especiallv 
a  child)    to  the  frame.      (See  Fig.   632.)  »  i-  \     f  . 

the  patient  is  placed  in  bed  a  Buck's  extension  apparatus  should  be 
applied  to  control  the  spasm  in  the  thigh  muscles.  Coaptation 
splints  and  a  long  side  or  T-splint  should  be  employed  in  prepara- 
tion for  the  first  week's  treatment,  during  which  time  the  traumatic 
reaction  is  to  take  place. 


566  FRACTURES   AND   DISLOCATIONS 

Diiriiiuf  tlio  first  week  or  ten  days  the  usual  ease  of  simple  fracture 
of  the  tlii»rh  is  treated  by  means  of  Buek's  extension,  eoaptalion 
splints  and  the  h)iit:-  side  splint,  liiifk's  extension  and  the  long 
side  or  T-si)lint  iiave  already  been  desei-ibed  under  the  treatment 
of  fractures  of  the  fenmral  neck.  ('oa})1ation  splints  are  short, 
light  splints  suri'ounding  lln'  thiyli  at  the  seat  of  fracture  and  ai'e 
often  misusetl  witii  the  idea  of  forcing  the  fragments  together  by 
means  of  lateral  pressure.  They  serve  a  purpose  in  the  treatment 
of  these  cases  but  their  value  has  been  greatly  overestimated.  They 
are  fairly  efficient  in  maintaining  reduction  after  it  has  been  accom- 
plished but  have  little  or  no  effect  in  forcing  displaced  fragments 
back  into  position.  If  applied  too  tightly  they  are  capable  of  doing 
considerable  harm  by  interfering  with  the  circulation  or  ))y  forcing 
the  nnisclcs  against  sharp  fragments.  The  coaptation  splints  should 
be  well  padded  and  are  best  held  in  i)Osition  by  means  of  circular 
strips  of  adhesive  ])laster. 

All  the  materials  for  the  application  of  Buck's  extension,  together 
witii  the  side  splint  and  coaptation  splints  should  be  at  hand  and 
ready  for  use  before  the  parts  are  disturbed.  It  will  usvially  be 
best  to  have  the  patient  anesthetized  to  relax  the  muscles.  The 
thigh  should  be  brought  back  into  alignment  with  as  little  manipu- 
lation as  possible.  An  attempt  at  accurate  apposition  of  the  frac- 
tured surfaces  should  be  made  at  this  time,  yet  reduction  immedi- 
ately following  the  accident  is  usually  only  partially  successful. 
This  is  because  most  fractures  of  the  shaft  are  oblique  or  spiral,  and 
although  anesthesia  relaxes  the  muscles,  yet  when  the  patient 
regains  consciousness  the  spasm  is  almost  sure  to  again  displace  the 
fragments,  even  though  heavy  extension  is  employed.  As  a  rule  the 
best  that  can  be  expected  at  this  time  will  be  an  approximate 
reposition.  Proper  reduction  can  best  be  accomplished  at  the  end 
of  four  or  five  days,  or  a  week,  when  the  extension  apparatus  has  so 
exhausted  the  muscles  that  the  displacing  strain,  resulting  from 
local  spasm,  is  practically  negligible,  when  guarded  by  a  heavy 
weight  at  the  end  of  the  extension  cord.  An  accurate  knowledge 
of  the  nature  and  position  of  the  fracture  is  most  valuable  in 
attempting  a  iDermanent  reduction,  and  for  this  reason  an  X-ray 
plate  should  be  taken  soon  after  the  accident.  By  a  study  of  the 
Rontgenogram  and  the  symptoms  of  the  case  we  are  able  to  deter- 
mine whether  ordinary  treatment  will  give  good  results  or  whether 
operative  intervention  will  be  necessary  to  accomplish  and  main- 


FRACTURES   OF   THE   FEMORAIj   SHAFT  567 

tain  good  reduction.  In  a  simple  transverse  fracture  it  will  often 
be  possible  to  secure  a  satisfactory  engagement  without  operation, 
but  when  the  fracture  is  spiral  or  oblique,  as  is  so  frequently  the 
case,  it  will  usually  be  necessary  to  resort  to  the  open  method  to 
obtain  the  best  results.  Non-operative  treatment  is  reserved  for 
those  rare  cases  in  which  good  reduction  can  be  accomplished  and 
maintained  by  manipulation  and  traction  and  immobilization,  and  in 
cases  in  which  operation  is  contraindicated  on  constitutional 
grounds.  If  good  reduction  is  possible  without  operation  the  case 
may  be  treated,  until  union  takes  place,  with  the  apparatus  just 
described :  namely  Buck 's  extension,  coaptation  splints  and  the  long 
side  splint  or  the  T-splint.  After  the  traumatic  reaction  has  sub- 
sided the  cast  may  be  employed  instead  of  the  above  apparatus. 
The  cast  is  usually  applied  with  the  lower  extremity  in  the 
straight,  extended  position,  but  if  the  surgeon  finds  that  some  other 
position  is  more  favorable  to  the  retention  of  the  fragments,  he 
should  employ  whatever  attitude  is  thus  shown  to  be  best  adapted 
to  the  needs  of  the  case.  In  any  event  the  cast  should  extend  from 
the  waist  to  the  foot  and  should  be  lined  with  sheet  cotton  to 
prevent  irritation.  The  upper  portion  of  the  cast  secures  a  firm 
hold  on  the  pelvis  while  the  lower  portion  immobilizes  the  thigh 
and  leg. 

In  fractures  of  the  upper  third  of  the  shaft  the  upper  fragment 
frequently  shows  a  tendency  to  outward,  or  outward  and  forward, 
displacement  and  accordingly  moderate  flexion,  or  flexion  with 
abduction,  is  often  found  to  be  the  position  favoring  retention. 
This  may  be  obtained  by  means  of  the  double  inclined  plane,  with 
extension  from  the  knee  in  the  line  of  the  axis  of  the  femoral  shaft, 
or  a  cast  may  be  applied  with  the  hip  slightly  flexed,  or  flexed 
and  abducted,  with  a  corresponding  position  of  flexion  at  the 
knee. 

In  fractures  in  the  lower  third  of  the  bone  the  lower  fragment  is 
often  displaced  backward  by  the  action  of  the  gastrocnemius,  and 
when  this  occurs,  flexion  at  the  knee  is  the  position  in  which  the 
condition  should  be  treated  and  the  double  inclined  plane,  or  cast 
in  flexion,  are  the  appliances  used.  ( See  Chapter  XXXIX,  ' '  Frac- 
tures of  the  Lower  End  of  the  Femur. ' ' ) 

These  attitudes  of  fixation  may  favor  the  retention  of  fragments 
but  are  seldom  really  efficient  in  accomplishing  good  results.  The 
fact  that  these  positions  are  needed  to  favor  reduction  and  retention 


568  FRACTURES   AND   DISLOCATIONS 

usually  means  that  the  ease  should  be  subjected  to  operation  to 
aceoniplish  really  good  apposition. 

In  children  under  ten  years  of  age,  fractures  of  the  femoral 
shaft  are  best  treated  by  vertical  suspension  of  the  lower  extremity, 
while  the  child  rests  on  a  Bradford  frame  in  the  recumbent  position. 
A  Buck's  extension  apparatus  is  applied  as  already  described  in 
the  treatment  of  fractures  of  the  hip,  with  this  exception,  the  line 
of  extension  is  vertical  instead  of  horizontal.  The  cord  passes 
through  a  pulley  directly  over  the  middle  of  the  bed  and  on  a 
vertical  line  with  the  hip.  The  lower  extremity  is  thus  maintained 
in  a  position  perpendicular  to  the  trunk.  It  is  best  to  have  the 
child  secured  to  a  Bradford  frame,  which  greatly  facilitates  the 
after-care  of  the  case  and  prevents  the  patient  from  moving  about 
to  the  extent  of  disturbing  the  fixation.  This  position  of  vertical 
extension  is  maintained  for  about  two  weeks,  after  which  the  lower 
extremity  is  lowered  to  an  inclined  plane  (about  40  degrees),  and 
extension  kept  up  in  this  position  for  another  week.  A  plaster 
spica  of  the  pelvis  and  lower  extremity,  or  a  hip  brace,  may  then 
be  applied  and  the  patient  allowed  up  and  about  with  the  aid  of 
crutches  and  a  high  sole  on  the  shoe  of  the  opposite  foot.  The  thigh 
should  not  be  subjected  to  strain  until  the  surgeon  is  sure  of  solid 
union,  otherwise  a  bowing  deformity  may  result.     (See  Fig.  632.) 

Fractures  of  the  thigh  in  patients  advanced  in  years  present  some 
of  the  same  problems  already  described  under  the  treatment  of 
fractures  of  the  hip  in  the  aged  (see  page  547).  Hypostatic 
pneumonia  or  bedsores  and  other  complications  may  develop  if  the 
patient  is  long  confined  to  bed.  Accordingly  some  form  of  ambu- 
latory treatment  should  be  adopted  as  soon  as  the  shock  and 
traumatic  reaction  have  subsided.  The  Thomas  hip  splint,  plaster 
cast,  or  "ambulatory  pneumatic  splint"  with  hip  attachment  may 
be  used  in  getting  the  patient  on  his  feet.  In  very  old  and  feeble 
persons  it  is  often  best  to  employ  the  cast  (see  page  548)  with  the 
thigh  and  knee  flexed  so  that  they  may  sit  in  a  chair  during  the 
day  and  rest  in  bed  at  night. 

In  fractures  of  the  femoral  shaft  in  the  new-born  the  thigh  is 
best  treated  in  complete  flexion,  being  bound  to  the  trunk  in  this 
position.  The  fcetal  attitude  is  thus  taken  advantage  of  to  secure 
immobilization.  The  thigh  and  abdomen  are  previously  dried  and 
powdered  and  a  few  layers  of  soft  linen  placed  between  them, 
before  the  thigh  is  fixed. 


FRACTURES   OF   THE   FEMORATj   .SHAFT  569 

In  fractures  of  the  lower  third  with  backward  displacement  of 
the  lower  fragment  the  double  incline  plane  may  be  used  instead  of 
the  plaster  cast  and  is  nuich  more  appropriate  in  the  early  part  of 
the  after-treatment,  during  the  time  the  acute  traumatic  inflamma- 
tion is  at  its  height. 

Operative  Treatment. — A  large  proportion  of  fractures  of  the 
femoral  shaft  demand  operative  intervention  if  the  best  possible 
results  are  to  be  obtained.  Fractures  of  the  upper  and  middle 
thirds  are  usually  of  the  spiral  or  oblique  type  and  nothing,  as  a 
rule,  will  secure  the  fragments  in  accurate  apposition  except  direct 
fixation  following  open  reduction.  In  the  lower  third  of  the  shaft 
it  is  more  often  possible  to  secure  good  reduction  by  non-operative 
treatment,  yet  fracture  in  this  region  often  demands  the  open 
method.  The  shaft  of  the  bone  is  usually  best  exposed  through  a 
longitudinal  incision  on  the  outer  aspect  of  the  thigh  in  the  region 
of  the  fracture.  With  the  fragments  exposed,  strong  traction  is 
made   on   the   lower   extremity   and   the    serrated   surfaces   fitted 


Fig.  635. — The  Nichols  frame.  An  appliance  of  ^reat  advantage  in  operating  on 
fractures  of  the  femoral  shaft.  A  steady  and  powerful  traction  is  maintained  on  the 
limb  during  the  operation. 

together.  They  are  then  secured  by  means  of  wire  or  a  heavy  Lane 
plate.  The  Nichols  extension  frame  is  one  of  a  number  of  appli- 
ances which  are  of  value  in  exerting  traction  and  countertraction 
during  operation  (see  Fig.  635).  Nowhere  in  the  body  is  internal 
fixation  subjected  to  greater  stress  than  here  in  the  shaft  of  the 
femur,  and  the  material  used  should  be  strong  enough  to  serve  the 
purpose,  pending  the  formation  of  bony  callus.  A  good  example  of 
the  fixation  of  a  double  spiral  fracture  of  the  middle  of  the  femoral 
shaft  with  wire  is  shown  in  Figs.  636  and  637.  ~Wlien  wire  is 
employed  two  points  of  fixation  should  be  had  to  secure  the  proper 
leverage  and  to  prevent  angular  deforrait}^  If  the  wire  is  passed 
circularly  about  the  shaft  it  will  often  accomplish  as  much  as  if  it 
were  passed  through  drill  holes  in  the  bone.     In  encircling  the  shaft 


570 


FRACTURES   AND   DISLOCATIONS 


the  instrument  carrying  the  Avire  should  hug  the  bone  closely  to 
avoid  injuring  the  femoral  artery  or  one  of  its  ])erforating  branches 
uhieh,  in  the  middle  third  of  the  shaft,  lie  in  close  relation  with  the 
internal  hoi-dt-r  of  the  bone.  If  a  Liiuc  ])late  is  used  it  should  be 
heavy  and  long,  ijrefcrably  of  the  Sherman-lMerce  type,  and  should 
be  provided  with  six  screw  holes.     When  the  fixation  is  completed 


UJU. 


Fig.    637. 


Fig.  636. — Double  spiral  fracture  of  femur  with  unattached  fragment.  X-ray  p'.ate 
taken  after  everything  in  a  non-operative  way  had  been  done  to  accomplish  reduc- 
tion. 

Pig.  637. — Same  case  after  operation.  Fragments  in  accurate  apposition  with  the 
result  that  the  lower  extremity  shows  no   shortening. 

the  thigh  should  be  raised  from  the  table  and  in  this  position  it 
should  be  capable  of  sustaining  the  weight  of  the  leg  without  giv- 
ing. The  muscles  should  be  brought  together  with  a  running 
suture  of  catgut  and  the  skin  closed  with  silk-worm  gut  or  horse 
hair.  A  plaster  cast  should  then  be  applied,  after  proper  dressings 
have  been  placed  on  the  wound  and  the  lower  extremity  covered 


FRACTURES   OF   THE   FEMORAIi   SHAFT 


571 


with  sheet  cotton.  The  cast  should  extend  from  the  waist  to  the 
foot,  leaving  the  toes  exposed,  so  that  the  condition  of  the  circula- 
tion in  the  extremity  may  be  watched  during  the  after-treatment. 
Twenty-four  to  forty-eight  hours  following  the  operation  a  window 
should  be  cut  in  the  cast,  the  wound  inspected  and  gentle  pressure 


Fig.   638 


Fig.   639. 


Fig.  638. — Same  case  two  j-ears  following  operation.  Perfect  restoration  of  func- 
tion. 

Fig.  639. — Same  case  six  years  after  operation.  Note  the  condition  of  the  callus 
and  wires,  also  the  reopening  of  the  medullary  canal. 


made  to  express  any  dead  blood  which  may  have  collected  in  the 
wound. 

In  compound  fractures  of  the  thigh  operative  intervention  is 
practically  always  indicated.  The  wound  should  be  enlarged  if 
necessary  and  all  devitalized  tissue  trimmed  away.  When  this 
has  been  done  the  wound  should  be  washed  with  a  few  gallons  of 
sterile  salt  solution  and  the  muscles  and  skin  accurately  approx- 


572  FRACTURES    AND    DISLOCATIONS 

iiuated    (sec    "Treatment    of    Coiiipoimd    Fractures,"    page    789). 

After-Treatment. — Tlie  duration  ul'  the  after-treatment  varies 
considerably  with  the  accuracy  of  apposition  and  the  age  of  the 
patient.  Union  will  therefore  take  longer  in  non-operated  cases 
tliau  in  eases  which  have  been  subjected  to  the  open  metliod  (see 
"Ol)erative  Treatment  of  Fractures,"  page  75-4).  in  a  healthy 
adult,  union  will  usuallj'  have  taken  place  in  from  six  weeks  to  two 
months,  although  refracture  may  easily  occur  at  this  time  if  the 
limb  is  subjected  to  any  considerable  strain.  In  children  union 
can  usually  l)e  expected  in  from  four  to  six  weeks.  In  the  aged 
union  may  be  very  much  delayed  and  in  some  cases  it  may  be 
impossible  to  obtain  l)ony  uiuon  at  all.  No  matter  what  line  of 
treatment  is  followed  the  case  should  receive  the  most  careful  atten- 
tion during  the  after-treatment.  The  patient  should  be  seen  daily 
for  the  first  few  weeks.  If  the  fracture  is  treated  by  extension  and 
splints,  frequent  adjustments  will  be  necessary  to  keep  the  patient 
comfortable  and  to  maintain  the  fragments  in  proper  position. 
During  the  first  few  days  the  weight  should  be  heavy  (usually  about 
twenty-five  pounds  in  the  adult)  to  control  the  spasm  in  the  thigh 
muscles  which,  at  this  time,  is  at  its  height.  The  w^eight  should  be 
graduallj"  diminished  as  the  muscles  become  exhausted  and  the 
spasm  less  active.  Frequent  measurements  of  the  lower  extremity 
should  be  made  to  determine  the  extent  of  the  shortening  and  the 
influence  of  the  extension  apparatus  in  overcoming  it.  If  the  cast 
or  ambulatory  splint  is  used  it  will  require  adjustment  from  time 
to  time  and  the  parts  with  which  it  comes  in  contact  should  be  care- 
fully watched  for  evidences  of  irritation.  If,  during  the  time  the 
cast  is  being  worn,  the  patient  complains  of  persistent  irritation  in 
a  given  place,  a  window  .should  be  made  to  determine  the  condition 
of  the  skin  or  to  treat  a  sore  if  one  has  developed.  Following  oper- 
ative intervention  the  temperature  chart  should  be  watched  for 
evidences  of  infection  and  the  wound  should  be  inspected  within 
the  first  few  days.  Infection  need  not  be  expected,  however,  if  the 
proper  surgical  technique  has  been  followed  out. 

If  ambulatory  treatment  is  not  employed  it  is  usuall}^  best  to  keep 
the  patient  in  bed  for  a  week  or  so  following  the  removal  of  the 
splints.  During  this  time  massage  and  passive  motion  should  be 
in.stituted.  AVhen  the  patient  is  first  allowed  up  no  weight  should 
l)e  borne  on  the  injured  member  until  he  is  thoroughly  adept  with 
the  crutches.     The  thigh  should  be  inspected  daily  during  the  time 


FRACTURES   OF    THE   FEMORAL   SHAFT  573 

he  is  beginning  to  bear  weight  on  it  and  if  the  slightest  evidences 
of  bowing  develop  he  should  be  again  placed  in  bed  and  extension 
apparatus  applied.  It  is  advisable  at  this  time  to  have  an  X-ray 
plate  made  to  determine  the  condition  of  the  callus. 

Prognosis. — Fracture  of  the  femoral  shaft  is  always  a  serious 
accident  and  the  prognosis  should  be  guarded.  In  unoperated  cases 
shortening  is  the  rule  and  angular  or  rotary  deformity  is  not 
uncommon.  If  the  shortening  is  less  than  an  inch  or  an  inch  and  a 
half,  and  the  general  alignment  of  the  shaft  is  not  changed,  the 
result  is  said  to  be  good.  If  the  shortening  is  not  greater  than  an 
inch  and  a  half  the  tipping  of  the  pelvis  will  compensate  for  the 
deficiency  in  the  length  of  the  lower  extremity  so  that  walking  will 
be  practically  normal.  Pain  and  weakness  in  the  injured  thigh 
are  common  following  fracture  of  the  femoral  shaft  and  often 
persist  for  years.  Little  can  be  done  to  alleviate  them.  The  more 
perfect  the  reduction  the  more  complete  and  prompt  will  be  the 
restoration  of  function.  The  results  following  the  open  treatment 
with  internal  fixation  of  the  fragments  are  decidedly  better  than 
those  following  the  non-operative  method.  It  is  often  possible  to 
secure  union  without  shortening,  even  in  spiral  fractures,  if 
recourse  is  had  to  operative  intervention. 

If  infection  follows  a  compound  fracture  the  outlook  is  often 
serious.  With  free  drainage  of  the  parts  the  danger  is  greatly 
reduced  and  bony  union  may  follow. 


CHAPTER  XXXIX. 
FRACTURES  OF  THE  LOWER  END  OF  THE  FEMUR. 

ruder  1liis  lu'adiiig  are  im-liKled  the  various  fractures  oeeurrinj^ 
in  the  lower  end  of  the  bone,  some  of  which  enter  the  joint  cavity 
of  the  knee.  Separation  of  the  lower  femoral  epiphysis  is  also  con- 
sidered under  this  heading  instead  of  being  taken  up  separately  as 
is  custoinai-y. 

Surgical  Anatomy. — The  lateral  surfaces  of  the  large  expanded 
lower  extremity  of  the  femur  are  subcutaneous  and  can  be  palpated 
without  difficulty.  With  the  knee  flexed  the  upper  margin  of  the 
trochlear  surface  may  be  felt  anteriorly.  The  two  heads  of  the 
gastrocnemius  are  attached  posteriorly  just  above  the  condyles.  To 
the  external  surface  of  the  outer  condyle  (outer  tuberosity)  is 
attached  the  tendon  of  the  popliteus,  and  at  the  lower  end  of  the 
external  supracondylar  ridge  is  the  origin  of  the  plantaris.  In 
the  notch  between  the  condyles  are  attached  the  upper  ends  of  the 
crucial  ligaments.  The  popliteal  artery  lies  in  close  relation  with 
the  posterior  surface  of  the  bone,  from  the  point  where  it  crosses 
the  internal  supracondylar  ridge  to  the  bottom  of  the  intercondyloid 
notch.  It  may  be  injured  in  this  position  when  fracture  of  the 
lower  end  of  the  bone  occurs.  The  vessel  is  more  often  temporarily 
compressed  than  permanently  injured,  which  fact  accentuates  the 
importance  of  early  reduction.  The  popliteal  nerve  and  vein  lie 
more  superficially  than  the  artery,  and  accordingly  are  much  less 
frequently  injured  by  displaced  fragments. 

The  most  common  fracture  of  the  lower  end  of  the  femur  is  trans- 
verse and  a  short  distance  above  the  condyles.  Occasionally  the 
lower  fragment  is  split  vertically,  thus  producing  the  typical  T-  or 
Y-fracture  which  enters  the  joint  cavity.  A  more  severe  type  of 
T-fracture  is  one  in  which  the  lower  end  of  the  shaft  is  driven  into 
the  lower  fragment  with  considerable  comminution  and  a  vertical 
splitting  into  the  intercondyloid  notch.  If  it  were  not  for  the  inter- 
condyloid notch  the  T-fracture  would  probably  not  occur. 

Either  condyle  may  be  broken  off  from  the  remainder  of  the  bone. 

574 


FRACTURES    OP    LOWER    END   OF   FEMUR  575 

When  force  is  applied  to  the  knee  in  a  lateral  direction  or  when 
violence  is  transmitted  longitudinally  through  the  leg,  the  tuber- 
osities of  the  tibia  play  an  important  part  in  the  pressure  they  may 
exert  against  the  condyles  of  the  femur.  In  like  manner  the  pull 
of  the  lateral  ligaments  may  result  in  fracture  of  a  condyle  when 


Fig.   640. 


Fig.    640. — Lateral   view   of   tlie   lower   end   of   the   femur. 
Fig.    641. — Coronal    section    of    the   lower    end    of    the    femur. 

the  knee  is  subjected  to  lateral  angmlar  displacement.  It  is  more 
common  for  the  lateral  ligaments  to  tear  away  only  their  bony 
attachments  on  the  femoral  tuberosities.  This  condition  is  usually 
represented  by  a  portion  of  the  surface  compact  tissue,  together 
with,  gome  of  the  underlying  cancellous  bone,  remaining  attached  to 


576 


FRACTURES   AND    DISLOCATIONS 


the  ligament  wliieli  is  torn  away  ami  disijlaced  from  the  tuberosity. 
This  type  of  fraetui't^  is  more  i)roperly  a  complieation  of  siihluxa- 
tions  or  "sprains"  of  1he  knee,  and  will  he  considered  under  "Dis- 
locations of  the  Knee."  \)i\ffe  613. 

The  epiphyseal  cartilage  corresponds  i-oughiy  to  a  horizontal 
plane  passing  just  above  the  condyles  and  througli  tlie  adductor 
tubercle.  The  top  of  the  trochlear  surface  just  touches  this  i)lane. 
The  lower  femoral  epii)hysis  is  ossiiietl  from  a  center  which  makes 


Fig.   642. — Kontgenogrum   of   the   knee   showing  the  locations   of   the   epipliyseiil   car- 
tilages. 


its  appearance  shortly  after  birth.  Epiphj'seal  separations  cannot 
occur  after  the  twentieth  year  since  the  epiphysis  joins  the  shaft 
at  this  time.     In  fact  they  are  rare  after  the  sixteenth  year. 

The  injuries,  then,  to  wdiich  the  lower  end  of  the  femur  is  subject 
are :  supracondylar  fracture,  T-fracture,  fracture  of  either  condyle 
separating  it  from  the  remainder  of  the  bone,  epiphyseal  separa- 
tion and  avulsion  of  a  portion  of  the  surface  of  a  tuberosity  by  the 
pull  of  the  ligaments.  In  rare  instances  we  may  see  a  longitudinal 
splitting  of  the  lower  end  of  the  shaft  which  extends  through  the 


FRACTURES    OF    LOWER    END    OF    FEMUR 


577 


Fig.   643. 


Fig.    644. 


Fig.    643. — Fracture   of   the   lower   end   of   femur   with    anguhir    deformity    and   cru.sli- 
ing  of  cancellous  tissue  in  the  lower  fragment. 

Fig.    644. — Supracondylar   fracture   with   pronounced   overriding    deformity. 


Fig.    645 


Fig.    645. — Old   displaced  fracture   with  refracture   through   callus. 
Fig.   646. — ^Fracture  of  femur  with  lateral  overriding  deformity. 


578 


FRACTURES   AND    DISLOCATIONS 


lower  end  of  tlie  bone  into  the  joint  cavity.  In  some  eases  we  may 
see  a  portion  of  the  surface  of  the  tuberosity  driven  inwai-d  hy 
severe  violence  confined  to  a  small  area. 

Symptoms. — The  symptoms  vary  with  the  age  of  the  patient  and 
the  severity  and  nature  of  the  injury.  In  supracondylar  fracture, 
fracture  of  one  of  the  condyles  or  epiphyseal  separation,  the  loss  of 
function  is  complete.  Tlie  patient  is  unable  to  stand  on  the  injured 
member  or  to  raise  the  foot  from  the  bed.  Deformity  is  usually 
present  and  varies  with  the  position  of  the  fracture.  In  the  simple 
sui)racondylar  type  the  lower  fragment  may  be  displaced  in  any 


Ki;;.  647. — Fracture  of  the  lower  third  of  the  femoral  shaft.  Note  llio  shortoninsc, 
external  rotation  and  thickening  of  the  thigh.  Lower  fragment  displaced  posteriorly. 
Case  first  seen   twenty-four  hours  after  injury  at  which  time  this  photograph  was  taken. 


Fig.    648. — L'(iiii]hiiiimI     i-niniiiiniil<Hl    fracture    "f    Ihr     Inwri-    .nil  oi     ili.-     i.niiw.  Tlie 

lower    end    of    the    upper    fragment    is    displaced    anteriorly    and    has  penetrated    tlie  skin. 

The   resulting   wound   shows   black   in   the  photograph   and  blood   is  seen   trickling  down 
the  side  of  the  knee. 


direction.  If  it  is  free  to  move  (if  not  obstructed  by  the  lower  end 
of  the  upper  fragment)  the  action  of  the  gastrocnemius  will  tend 
to  displace  it  backward.  In  any  type  of  fracture  of  the  lower  end  of 
the  femur  it  is  more  common  to  see  the  lower  end  of  the  upper 
fragment  displaced  forward  and  downward  while  the  lower  frag- 
ment is  displaced  backward.  In  epiphyseal  separations  the  reverse 
is  usually  true,  the  epiphysis  is  displaced  forward  and  upward,  in 
front  of  the  lower  end  of  the  diaphysis.     In  T-fracture  or  fracture 


FRACTURES   OF    LOWER   END   OF    FEMUR  579 

of  one  of  the  condyles  the  transverse  diameter  of  the  lower  end  of 
the  femur  is  usually  increased.  Injury  to  the  popliteal  artery  may 
occur  in  any  of  these  fractures  of  the  lower  end  of  the  femur, 
especially  in  epiphyseal  separations,  and  the  resulting  symptoms 
of  disturbed  or  destroyed  circulation  will  depend  on  whether  or  not 
the  artery  has  been  compressed  or  lacerated.  In  fractures  of  the 
lower  end  of  the  femur  it  is  not  uncommon  to  see  the  lower  end  of 
the  upper  fragment  projecting  through  the  skin  above  the  patella. 
In  epiphyseal  separations  the  condition  is  often  rendered  compound 
by  the  lower  end  of  the  diaphysis  projecting  through  the  skin  cov- 
ering the  popliteal  space. 

Abnormal  mobility  is  regularly  present  but  the  proximity  of  the 
knee  joint  renders  this  symptom  at  times  difficult  to  recognize.  In 
fracture  of  one  of  the  condyles  or  in  T-fracture  the  loss  of  lateral 
stability  in  the  knee  is  usually  pronounced.  Crepitus  may  be 
elicited  unless  the  fragments  have  overridden  so  that  their  serrated 
surfaces  are  no  longer  in  contact.  In  epiphyseal  separations  the 
epiphysis  is,  as  a  rule,  displaced  anteriorly  and  uj^ward  and 
crepitus  cannot  be  elicited  until  the  fractured  surfaces  are  brought 
back  into  contact  and  even  then  it  is  soft  and  cartilaginous  rather 
than  bony. 

Diagnosis. — If  the  case  is  seen  early  before  the  onset  of  swelling, 
it  will  usually  not  be  difficult  to  recognize  the  nature  of  the  injury. 
There  is,  as  a  rule,  disturbance  in  the  alignment  of  the  bones  of 
the  thigh  and  leg  which  can  be  determined  by  inspection.  Short- 
ening of  the  thigh  is  the  rule  since  the  fragments  so  frequently 
override.  Fracture  in  this  region  without  deformity  is  the  excep- 
tion. Abnormal  mobility  is  usually  characteristic.  The  lateral 
stability  of  the  knee  is  impaired,  especially  when  the  lower  fragment 
is  divided  into  two  or  more  pieces.  "Where  the  swelling  is  great  it 
may  be  difficult  to  determine  whether  the  fracture  is  in  the  lower 
end  of  the  femur  or  the  upper  end  of  the  tibia. 

The  deformity  in  these  fractures  is  variable,  though  the  most 
common  displacement  is  backward  in  the  lower  fragment.  In 
epiphyseal  separations  the  deformity  is  more  uniform  with  the 
epiphysis  displaced  upward  and  forward.  This  condition  is  most 
commonly  seen  about  the  tenth  or  twelfth  year  and  the  crepitus 
elicited  is  soft  and  cartilaginous  rather  than  bony. 

All  unnecessary  manipulation  for  diagnostic  purposes  should  be 
avoided  because  of  the  liability  of  injury  to  vessels  and  nen-es. 


580 


FRACTURES   AND   DISLOCATIONS 


Tlic  inniiipiiljitioiis  incident  to  I'lHhiction  will  jilTord  as  iniicli 
inroniiat  ion  to  Ihc  surgeon  as  those  condncted  siiii|)ly  to  t'stablish  a 
diagnosis.  When  the  X-ray  is  available  the  most  coiuplete  informa- 
tion concci'ninii'  tlic  t'i'aci  lire  may  he  gained  williout  distiirhing  the 
parts. 

Treatment. — Anesthesia  is  esst'ntial  in  redm-ing  I'l-aetures  of  tlie 
lowei-  end  of  the  fennir.  AVith  a  simple  snpi-aeondylar  fracture 
reduction  should  h(^  aeeomplished  as  soon  as  i)Ossible  and  the  frag- 
ments imiiml)ili/.ed  in  splints.  Diffienlty  is  sometimes  experienced 
ill  liringiiiLi'  the  fraelured  surfaces  hack  into  apposition  and  when 
such  is  tile  case  we  should  resort  to  operative  intervention.     The 


A 


B 


^  --     .-,«,» 

^—-J'—l 

L  '      I"' 

'ii;.-.; 

\\  '! 

r_ii  Hi-i 

-Lll—l jj_ 

i^A-.    K 

I  1,   A  -  '   -H; 

\\\ 

c 

H 

Pig.  649. — Cabot  posterior  wire,  hip  splint.  A.,  Wire  bent  to  make  splint.  B., 
Side  view  showing  bends  to  conform  to  the  posterior  surface?  of  the  lower  extremity  and 
hips,  with  knee  in  a  position  of  slight  flexion.  C,  Splint  covered  and  lateral  flaps  at- 
tached to  encircle  the  trunk. 


()'>(!. — CmIioI    |i(islci-iijr    wire   .siilint    licnt    t(i   lie    nscil    iis   (IuuIjIc    iiirliiird    ])l:in( 


fact  tliat  the  popliteal  artery  may  he  injured  during  reduction 
should  never  he  lost  sight  of  and  accordingly  manipulations  should 
be  most  guarded.  If  reduction  cannot  be  accomplished  by  traction 
and  manipulation,  tlie  open  method  should  be  instituted  at  once, 
especially  if  there  is  the  slightest  indication  that  tlie  popliteal  artery 
is  being  compressed.  In  manipulating  the  fragments  pressure 
should  never  be  made  in  the  i)opliteal  space  lest  the  arter}^  he  driven 


FRACTURES   OF   IjOWER   END   OF    FEMUR 


581 


against  the  end  of  one  of  the  fragments.  Pressure  to  force  the  lower 
end  of  the  upper  fragment  forward  should  be  made  in  the  middle 
of  the  thigh  posteriorly,  where  there  will  be  no  danger  of  injury  to 
important  soft  tissues.  In  the  presence  of  a  T-fracture  or  a  frac- 
ture of  one  of  the  condyles,  an  attempt  should  be  made  to  force  the 


Pig.  651. — Dupuy's  adjustable  splint  used  as  a  douljle  inclined  plane  in  a  case  of 
frnctuve  of  the  femur.  Extension  in  the  long  axis  of  the  femur  is  employed  to  maintain 
reduction. 


Fig.    652. — Dupuy's    adjustable    metal    splint    for    the    treatment    of    fractures    of    the 
lower    extremity. 

condyles  together  as  reduction  is  being  accomplished.  This  is  an 
important  matter  since  separation  of  the  femoral  condyles  means 
loss  of  proper  alignment  between  the  femoral  and  tibial  articular 
surfaces  with  subsequent  disturbance  in  the  function  of  the  knee 
joint.  If  the  fracture  is  near  the  knee  and  the  lower  end  of  the 
upper  fragment  is  displaced  forward  the  prominence  thus  produced 


582 


P^RACTURES   AND    DISLOCATIONS 


may  interfere  with  the  action  of  the  patella  and  (luadriceps  after 
union  lias  taken  place. 

In  separation  of  the  epiphysis  reduction  should  be  accomplished 
at  once  and  with  the  least  possible  manipulation.     Gradual  flexion 


ddnliU^    inclined    piano,    fracture    box. 


of  tile  kncM'  while  ])n'.ssui'c  is  being-  exerted  on  the  epiphysis  will 
aitl  iiiatci  ially  in  ctlVcting'  reduction.  If  reduction  cannot  be  ef- 
fected by  traction,  counter-traction,  flexion  and  direct  pressure  on 
the  epii)h>sis,  it  should  be  accomplished  by  operative  intervention. 


Fig.   654. — Hodden's   splfnt.     This   splint  may  be   used   as   a   double   inclined   plane. 
The  manner  in  which  the  ropes  are   arranged  affords  traction   as  well   as  suspension. 

Repeated  attempts  at  reduction  of  an  epiphysis,  with  intervals  of 
delay,  are  absolutely  to  be  condemned.  The  sequel  of  such  surgery 
is  amputation.  If  the  first  attempt  is  unsuccessful,  operation  should 
be  performed  at  once. 

Operative  Treatment. — Operation  is  indicated  when  good  reduc- 
tion cannot  otherwise  be  accomplished.  An  incision  along  the  inner 
border  of  the  quadriceps  extensor  wall  expose  the  fragments,  and 
manipulation  of  the  lower  extremity  may  be  aided  by  direct  trac- 
tion on  the  displaced  fragments,  by  means  of  bone  hooks  or  forceps. 
Increasing  the  angular  deformity  may  render  reduction  easy  w'hich 
would  otherwise  have  been  difficult.     After  the  serrated  surfaces 


FRACTURES   OF   LOWER   END   OF    FEMUR  583 

have  been  engaged  the  angular  deformity  is  corrected  and  tlie  frag- 
ments brought  back  into  good  alignment.  If  the  fracture  is  of  the 
T-type  it  is  often  advisable  to  make  two  longitudinal  incisions,  one 
on  the  inner  and  the  other  on  the  outer  aspect  of  the  thigh  opposite 
the  lower  end  of  the  bone.  With  the  parts  thus  exposed  the  condyles 
are  forced  together  and  back  into  position  so  that  they  properly  fit 
the  articular  surfaces  of  the  tibia.  If  a  tendency  toward  recur- 
rence of  deformity  is  noted  they  should  be  secured  in  proper  rela- 
tion with  each  other  by  some  means  of  internal  fixation.  If  two 
holes  are  drilled  transversely  through  the  lower  end  of  the  bone 
above  the  condyles,  a  wire  may  be  passed  through  the  bone  from 
one  side  to  the  other  and  back  again,  thus  holding  the  fragments 
together.  A  Lane  plate  may  be  used  on  the  anterior  surface  of  the 
bone  if  the  displacing  strain  is  not  too  great.  It  should  be  remem- 
bered that  the  lower  end  of  the  femur  is  covered  by  a  very  thin 
layer  of  compact  tissue  while  the  interior  of  the  bone  is  composed 
of  a  cancellous  structure  which  offers  an  exceedingly  poor  foothold 
for  screws,  nails  or  pegs.  The  most  secure  fixation,  therefore,  is  the 
transverse  wiring  just  described.  If  transverse  wiring  is  employed 
below  the  upper  border  of  the  trochlea  care  should  be  exercised  to 
avoid  drilling  into  the  supracondyloid  notch.  The  drill  holes 
should,  therefore,  be  placed  well  forward.  (See  "Anatomy  of 
Lower  End  of  Femur,"  page  574. 

The  knee-joint  should  not  be  opened  unless  it  is  found  that 
proper  fixation  cannot  otherwise  be  obtained.  "With  reduction  and 
fixation  of  the  fragments  accomplished  the  wound  or  wounds  are 
closed  and  the  lower  extremity  immobilized  in  whatever  position 
shows  the  least  tendency  toward  recurrence  of  deformity,  as  demon- 
strated during  operation.  Extension,  semiflexion  or  flexion  may 
be  employed.  As  a  rule,  however,  it  will  be  found  practicable  to 
immobilize  the  lower  extremity  on  a  ham  splint  in  a  position  just 
short  of  complete  extension.  "When  the  fracture  is  treated  in  this 
position  a  Buck's  extension  following  operation  is  usually  indi- 
cated to  relieve  the  muscular  spasm,  steady  the  member  and  re- 
lieve the  pressure  between  the  articular  surfaces  of  the  tibia  and 
femur.  Padding  of  the  splint  for  the  purpose  of  exerting  pres- 
sure in  the  popliteal  space  to  effect  or  maintain  reduction  is  not 
permissible.  Tenotomy  of  the  tendo  Achillis  to  overcome  backward 
displacement  of  the  lower  fragment  has  been  advised  and  prac- 


584  FRACTURES   AND   DISLOCATIONS 

tised  but  is  proliably  an  luiwise  measure.  It  is  often  imsiiccessful 
and  by  no  means  as  satisfaetory  as  open  treatment  with  direct 
fixation  of  the  fragments. 

Tliere  is  usually  little  tendency  toward  recurrence  of  deformity 
following  reduction  of  an  epiphyseal  separation,  if  the  lower  ex- 
tremity is  treated  in  the  semiflexed  position.  Should  the  excep- 
tion, however,  be  encountered  and  internal  fixation  prove  necessary, 
absorbable  suture  material  is  the  only  material  which  should  be 
used  in  holding  the  epiphysis  in  place.  Loops  of  wire  or  a  Lane 
plate  should  not  be  used  across  an  epiphyseal  cartilage.  A  light 
plaster  cast  extending  from  the  groin  to  the  ankle  with  the  knee 
in  semi-flexion  will  usually  be  found  quite  satisfactory  in  im- 
mobilizing the  parts.  It  should  not,  however,  be  employed  until 
after  the  traumatic  reaction  has  subsided.  If  the  cast  is  cut  open 
before  the  plaster  has  dried  it  may  be  applied  immediately  fol- 
lowing the  ojieration. 

After-Treatment. — Considerable  traumatic  reaction  usually  fol- 
lows the  accident,  and  during  the  first  week  repeated  adjustments 
will  be  necessary  in  making  allowances  for  the  onset  and  subsidence 
of  swelling.  Traumatic  arthritis  of  the  knee  is  the  rule,  especially 
in  epiphyseal  separations  and  fractures  entering  the  joint  cavity. 
The  knee  should  be  snugly  bandaged  and  an  ice  cap  should  be  kept 
in  position  most  of  the  time  during  the  first  week.  A  long  side 
splint  such  as  used  in  fractures  of  the  shaft  of  the  bone,  adds 
greatly  to  tlie  security  of  immobilization  when  the  fracture  is 
treated  in  the  extended  position.  If  the  lower  fragment  shows  a 
tendency  to  posterior  displacement  not  controlled  by  straight 
Buck's  extension,  a  double  incline  plane  should  be  employed  or  the 
lower  extremity  put  up  in  a  cast  in  a  flexed  or  semi-flexed  position. 
At  the  end  of  six  or  eight  weeks  the  dressings  should  be  removed 
and  passive  motion  begun.  In  another  week  or  ten  days  the  pa- 
tient may  be  allowed  out  of  bed  and  may  begin  the  use  of  the 
member  cautiously.  He  may  bear  a  little  weight  on  it  while  get- 
ting about  with  the  aid  of  crutches  and  a  moderately  high  sole  on 
the  opposite  foot. 

In  children  union  is  much  more  rapid  while  in  the  aged  it  may 
be  very  much  delaj^ed. 

The  usual  treatment  of  epiphyseal  separations  is  with  the  knee 
in  a  position  of  semiflexion.  At  the  end  of  three  or  four  weeks 
the  knee  may  be  carefully  brought  to  the  extended  position  and 


FRACTURES   OF    LOWER   END   OF   FEMUR 


585 


massage  begun.  Guarded  passive  motion  sliould  be  instituted 
within  the  next  few  days.  At  the  end  of  six  weeks  all  dressings 
should  be  removed  and  the  child  allowed  to  lie  unrestrained  in  bed 


Fig.  655. — Ambulatory  pneumatic  splint  (adjustable),  sliowino;  application  for  all 
fractures  but  the  hip,  without  any  additional  supports  to  the  limb  or  hip-joint  immobilizing 
attachment. 

for  another  two  weeks.  If  the  ambulatory  pneumatic  splint  is 
used,  or  some  other  equally  efficient  appliance,  the  child  may  be 
up  and  about  during  this  time.  Function  may  be  resumed  grad- 
ually during  the  eighth  and  ninth  weeks.     At  the  end  of  two  and 


586  FRACTURES   AND   DISLOCATIONS 

a  half  moiitlis  the  patit'iil  should  lie  hearing-  his  full  wt'i<;lit  on 
the  lejr. 

It"  at  any  time  ihiriiiii,'  the  at'tfv-ti'eatineiit  gaiijj;ri'ne  or  si'j)ti- 
cemia  should  develop  as  a  result  ol"  destroyed  cireulatiou  or  infec- 
tion, prompt  amputation  will  usually  be  necessary  to  save  the 
patient's  life. 

ProgTiGsis. — Fracture  of  the  lower  end  of  the  femur  is  at  best  a 
serious  condition.  Infection  of  the  knee-joint  or  laceration  of  the 
popliteal  artery  are  conditions  which  render  the  fracture  itself 
only  of  secondary  importance.  Epiphyseal  separation  has  a  par- 
ticularly bad  prognosis,  especially  when  compound.  Gangrene  of 
the  leg  is  not  an  uncommon  sequel  when  the  popliteal  artery  is 
injured  and  death  has  resulted  in  many  instances  from  gangrene, 
infection,  embolism,  etc.  Disturbances  in  the  subsequent  growth 
of  the  bone  following  epiphyseal  separations  are  not  common  if 
recovery  has  taken  place  with  the  fragments  in  good  reduction. 
The  surgeon,  however,  should  warn  the  parents  of  the  untoward 
possibility  so  that  he  may  not  be  unjustly  blamed  later  on. 

Simple  fracture  of  the  lower  end  of  the  femur  without  arterial 
damage  is  usually  followed  by  good  function  if  the  condyles  do  not 
unite  in  deformity.  Joint  adhesions  may  occur  in  the  knee.  Their 
severity  is  lessened  by  the  proper  use  of  Buck's  extension  during 
the  height  of  the  traumatic  arthritis.  A  chronic  villous  arthritis 
is  not  uncommonly  seen  following  fractures  in  this  region. 


CHAPTER  XL. 

FRACTURES  AND  LUXATIONS  OP  THE  SEMILUNAR 
CARTILAGES. 

Surgical  Anatomy. — The  semilunar  cartilages  are  two  crescentie 
masses  interposed  between  the  articular  surfaces  of  the  tibia  and 
femur  and  serve  to  deepen  the  articular  surfaces  on  the  head  of 
the  tibia.  The  superficial  margins  are  thick,  correspond  roughly 
with  the  outline  of  the  upper  end  of  the  tibia  and  are  attached  to 
the  deep  surface  of  the  capsule  of  the  knee-joint.  The  central 
margins  of  these  cartilages  are  thin  and  lie  free  in  the  joint.  Be- 
tween the  articular  surfaces  of  the  tibia  we  have  attached  from 
before  backward:  the  anterior  end  of  the  internal  semilunar  carti- 
lage, the  anterior  crucial  ligament,  the  anterior  end  of  the  external 
cartilage,  the  posterior  end  of  the  same  cartilage  and,  lastly,  the 
posterior  crucial  ligament.  It  will  be  seen  from  this,  that  the  two 
extremities  of  the  external  cartilage  practically  meet  at  the  spine 
of  the  tibia  while  the  extremities  of  the  internal  cartilage  are 
separated  by  a  considerable  distance.  The  deep  structure  of  these 
cartilages  is  fibrous  while  the  surface  is  composed  of  hyaline  carti- 
lage. They  are  triangular  on  cross-section.  The  circumference  of 
each  cartilage  is  bound  to  the  borders  of  the  tuberosities  of  the 
tibia  by  the  capsule  of  the  joint,  which  is  continuous  on  the  outer 
and  inner  aspects  of  the  articulation  with  the  lateral  ligaments. 
The  portion  of  the  capsule  thus  attaching  the  cartilages  to  the  tibia 
is  known  as  the  coronary  ligaments,  and  fibres  stretching  between 
the  anterior  convexity  of  the  two  cartilages  has  been  described  as 
the  transverse  ligament.  The  knee-joint  is  of  the  hinge  type  with 
complimentary  gliding  and  rotary  motion.  In  extension,  lateral 
motion  is  prevented  by  the  lateral  ligaments,  but  in  flexion  this 
function  is  performed  by  the  crucial  ligaments.  The  angle  at 
which  the  tibia  joins  the  femur  in  extension,  normally  throws 
greater  strain  on  the  internal  lateral  ligament  than  on  the  external. 
The  internal  cartilage  is  much  more  intimately  attached  to  the  in- 
ternal lateral  ligament  than  is  the  external  to  the  external  lateral 

587 


588  FRACTURES   AND   DISLOCATIONS 

ligament.  Kuiitnvc  and  displacement  of  llic  iiitornal  lateral  M^ii- 
ment  will  therel'ore  be  much  more  likely  to  disturb  the  internal 
cartilage  than-  Avould  be  the  case  with  the  external  cartilage  if  the 
external  ligament  were  injured.  The  normal  lateral  angle  of  the 
knee  is  such  that  the  longitudinal  stress  produced  by  th(>  weight  of 
the  body  tends  to  separate  the  articular  surfaces  on  tlic  inner  side 
of  the  joint.  The  circumference  of  the  cartilage  is  attached  to  the 
internal  lateral  ligament  and  when  this  structure  is  torn  the  carti- 
lage may  be  displaced  inward  and  jammed  between  the  articular 
surfaces.  "When  the  femur  is  displaced  laterally  on  the  tibia  the 
condyles  ride  upward  on  the  semilunar  cartilages  and  thus  serve 
to  bring  the  crucial  ligaments  to  a  tension.  In  si)rains  of  the  knee 
the  semilunar  cartilages  may  be  fractured  or  displaced.  They  may 
be  found  free  in  the  joint  or  only  partially  detached.  A  portion 
of  the  cartilage  may  be  fractured  and  partially  or  completely 
separated  from  the  remainder.  It  may  be  folded  upon  itself  and 
in  cases  of  long  standing  various  degenerative  changes  have  been 
noted  in  the  entire  joint  as  well  as  in  the  cartilage.  Cases  are  on 
record  in  which  the  cartilage  from  one  side  of  the  articulation  has 
been  found  on  the  opposite  side  of  the  joint  cavity. 

Symptoms. — In  the  typical  case  the  clinical  picture  is  quite 
characteristic.  The  patient  gives  a  history  of  having  been  taken 
with  severe  pain  in  the  knee  (usually  on  the  inner  side)  while  the 
joint  was  partly  flexed  and  under  strain.  The  joint  locked,  so 
tlijit  lie  was  unable  to  extend  the  leg,  thougli  it  may  have  been 
l)Ossil)]e  for  him  to  hobble  some  distance  with  the  knee  in  a  position 
about  half  way  between  complete  extension  and  semiflexion.  By 
repeated,  attempts  at  flexion  and  extension  or  Avith  medical  aid 
something  was  felt  to  give  within  the  joint  and  the  knee  was  again 
found  to  be  free  and  capable  of  full  extension. 

Following  the  accident  evidences  of  traumatic  arthritis  develop 
and  the  patient  is  confined  to  the  house  for  a  period  varying  from 
a  few  days  to  a  few  weeks  according  to  the  severity  of  the  reaction. 
It  is  during  this  time  that  the  .surgeon  usually  first  sees  the  case. 
If  the  patient  gets  about  as  soon  as  the  swelling  subsides  recurrence 
of  the  accident  is  almost  sure  to  occur  when  the  knee  is  subjected 
to  similar  strain  and  position.  The  reaction  following  subsequent 
luxations  is  usually  less  severe  than  that  attending  the  first  dis- 
placement. In  the  atypical  case  there  may  be  no  history  of  the 
knee  having  locked.     The  patient  may  complain  only  of  a  sense  of 


FRACTURES    AND    LUXATIONS    OF    SEMILUNAR    fl.A  HTII>  AOKS 


589 


insecurity  in  the  joint  and  of  pfiin  under  strain,  at  times.  In  old 
cases  the  only  evidences  of  tlie  condition  may  be  found  in  secondary 
changes  such  as  chronic  hypertropliic  artht-itis.  For  a  number  of 
days  following  the  accident  it  is  the;  rub;  to  find  tenderness  in  the 
region  of  the  cartilage,  usually  the  internal,  and  in  some  instances 


Fig.  65G. — Subluxation  of  the  knee  with  lateral  dislocation  of  the  patella.  The  in- 
ternal lateral  ligaments  are  torn  and  the  semilunar  cartilage  displaced  toward  the  spine 
of  the  tibia. 


Fig.   657. — Another  view  of  the   same   case   showing  how   the   iinger   may  be   inserted 
between  the  tibia  and  femur. 


a  gap  between  the  bones  may  be  produced  by  manipulation.  Pain 
may  be  referred  to  the  patella  rather  than  the  region  of  the  carti- 
lage though  the  tenderness  is  always  more  pronounced  at  the  site 
of  the  cartilage.  The  absence  of  physical  signs,  however,  is  char- 
acteristic following  the  traumatic  reaction.     Wlien  the  condition 


590  FRACTURES   AND   DISLOCATIONS 

becomes  recurrent  it  is  not  infrequently  (luite  disabling.  The  time 
consumed  in  recovering  from  the  traunuitie  reaction  and  the  sense 
of  insecurity  which  the  patient  experiences  during  the  intervals 
are  important  sources  of  disability.  The  fact  that  the  knee  may 
be  thrown  out  of  function  at  any  liiuc  deters  him  from  many  ac- 
tivities. The  degenerative  changes  which  so  often  follow  in  the 
articulation  are  important. 

Diagnosis. — With  the  typical  history  of  sudden  pain  and  "lock- 
ing" of  the  joint,  with  complete  release  of  the  articulation  when 
the  cartilage  is  reduced,  the  diagnosis  is  easy.  In  atypical  cases, 
however,  without  the  characteristic  symptoms  of  locking  of  the 
knee,  it  may  be  impossible  to  arrive  at  a  diagnosis  until  the  joint  is 
explored.  It  might  seem  that  a  diagnosis  should  be  made  in  all 
cases,  yet  experience  will  show  that  mistakes  are  common  even 
among  those  most  thoroughly  versed  in  the  internal  derangements 
of  the  knee.  "When  the  case  is  not  typical  the  condition  must  be 
differentiated  from :  dislocations  of  the  patella,  synovial  fringes, 
joint  mice,  lipomata  and  subluxations  of  the  knee. 

If  the  patient  is  seen  daring  the  acute  disability  there  will  be 
little  difficulty  in  differentiating  lesions  of  the  semilunar  cartilages 
from  luxations  of  the  patella.  If,  however,  we  are  obliged  to  rely 
on  the  histor,y  given  by  the  patient  it  may  become  an  extremely 
difficult  matter  to  arrive  at  a  diagnosis.  If  the  patella  has  been 
dislocated  the  region  of  the  knee  cap  will  be  tender  for  a  few  days 
following  the  displacement  and  it  is  often  possible,  especially  under 
anesthesia,  to  displace  the  bone  bej'ond  its  normal  limits.  ]\Iore- 
over  the  characteristic  tenderness  on  the  inner  side  of  the  knee  at 
the  site  of  the  semilunar  cartilage  is  absent.  If  the  case  is  seen 
some  wrecks  or  months  following  the  accident  it  may  be  impos.sible 
to  determine  the  conditions  that  existed,  if  the  patient  gives  the 
usual  imperfect  history.  When  s.ynovial  fringes  are  pinched,  the 
locking  is  not  as  pronounced  and  solid  as  occurs  in  luxations  of 
the  semilunar  cartilages.  Moreover  the  point  at  which  the  motion 
of  the  knee  is  interfered  with  is  not  constant  and  the  pain  is  usually 
more  intense  and  acute  than  occurs  when  the  semilunar  is  at  fault. 
When  joint  mice  are  present  it  may  be  possible  to  palpate  one  or 
more  of  the  loose  bodies  within  the  articulation,  and  the  point  at 
which  the  action  of  the  knee  is  interfered  with  varies  with  different 
attacks.  If  the  disturbance  in  function  is  due  to  lipomata  the  acute 
symptoms  are  less  severe  and  the  subsequent  acute  traumatic  ar- 


FRACTURES   AND   LUXATIONS   OF    SEMILUNAR    CARTILAGES         591 

thritis  is  usually  negligible.  In  addition  a  pepinanent  puffiness  is 
usually  noted  on  either  side  of  tlie  patellar  ligament  wliieli  repre- 
sents the  enlarged  fat  pad  beneath  the  ligament.  In  siibluxalions 
of  the  knee  the  history  of  trauma  and  the  abnormal  mobility  will 
usually  clear  the  diagnosis.  The  joint  cavities  have  been  injected 
with  hydrogen  and  the  X-ray  used  to  determine  the  outlines  of  the 
semilunar  cartilages  but  this  method  of  diagnosis  is  seldom  indi- 
cated in  general  practice.  When  it  is  employed  the  dangers  of 
infecting  the  articulation  should  be  kept  in  mind.  In  chronic  dis- 
turbances of  the  knee  the  important  points  to  be  determined  are 
whether  or  not  the  disturbance  in  function  is  sufficient  to  warrant 
opening  the  knee  and  whether  or  not  good  functional  results  can 
be  obtained  without  operation. 

Treatment. — If  the  case  is  seen  while  the  cartilage  is  luxated, 
reduction  should  be  effected  at  once.  Reduction  of  the  displaced 
cartilage  is  usually  easy  though  cases  are  occasionally  encountered 
in  which  open  incision  is  necessary.  Reduction  is  effected  by  acute 
flexion  of  the  knee,  the  leg  is  then  rotated  back  and  forth  on  its 
axis  and  laterally  deviated  from  side  to  side  and  finally  extended. 
In  acute  flexion  of  the  knee  the  most  convex  portions  of  the  femoral 
condyles  are  in  contact  with  the  articular  surfaces  of  the  tibia  and 
accordingly  there  is  more  room  for  the  cartilages  than  when  the 
knee  is  extended.  This  accounts  for  the  release  of  the  pinched 
cartilage  during  acute  flexion.  The  rocking  and  rotary  motions 
just  described  also  tend  to  free  the  cartilage.  If  the  surgeon  flexes 
the  knee  over  his  wrist,  the  latter  acts  as  a  fulcrum  and  aids  ma- 
terially in  separating  the  articular  surfaces  of  the  femur  and  tibia. 
If  these  manipulations  have  been  successful  and  the  cartilage  has 
been  freed,  complete  and  active  extension  of  the  knee  Avill  be  pos- 
sible and  painless.  If  they  have  failed  the  knee  will  be  blocked 
just  short  of  full  extension  and  the  patient  will  be  unable  to  hold 
the  leg  extended  in  the  horizontal  position.  Moreover  the  attempt 
will  be  attended  by  pain.  The  proof  of  reduction  is  the  free  active 
extension  of  the  joint  unattended  by  pain.  The  patient  will  almost 
invariably  be  able  to  state  when  the  cartilage  is  reduced.  His  con- 
duct reminds  one  of  luxations  of  the  shoulder  in  which  the  sufferer 
exclaims  with  satisfaction  as  the  head  of  the  bone  slips  back  into 
the  glenoid.  The  care  of  the  case  following  reduction  will  be  taken 
up  in  the  after-treatment. 

Operative  Treatment. — The  indications  for  operative  treatment 


592  FRACTURK8    AND    DISLOCATIONS 

vary  with  the  social  state  of  the  patient  and  the  nature  of  the 
lesion.  .  If  this  luxation  occurs  for  the  first  time  in  a  gentleman 
of  leisure,  who  has  ampk^  time  for  non-operative  methods  and  can 
avoid  subsequent  strain  to  the  joint,  the  condition  may  be  treated 
expectantly.  If  on  the  other  hand  the  patient  is  a  laboring  man, 
whose  time  and  activity  mean  his  living,  the  cartilage  causing  the 
trouble  should  be  removed  at  once.  The  advisability  of  operating 
following  the  first  luxation  is  a  question.  If  reduction  is  accom- 
plished and  the  joint  immobilized  for  a  period  sufficiently  long  to 
allow  complete  healing  of  the  ligaments  and  cartilage,  the  condition 
may  not  recur.  Cases  of  habitual  luxation,  with  or  without  evi- 
dences of  degenerative  changes  within  the  joint,  call  for  operative 
intervention.  Nothing  can  be  expected  from  non-operative  meth- 
ods under  these  circumstances. 

A  vertical  incision  is  made  beginning  about  one  inch  behind  the 
lateral  border  of  the  patella  and  a  little  above  the  horizontal  plane 
of  the  articulation.  This  is  carried  downward  across  the  articu- 
lation and  continued  backward  in  a  curved  direction  as  soon  as  the 
scalpel  comes  opposite  the  tuberosity  of  the  tibia.  After  the  skin 
incision  is  made  the  cutaneous  edges  are  covered  with  gauze,  whi-ch 
is  held  in  position  by  tenaculfe.  The  tissues  are  then  divided  down 
to  the  capsule  of  the  joint,  which  is  incised  with  the  least  possible 
trauma.  The  half  of  the  joint  cavity  to  be  operated  upon  is  then 
open  for  inspection  and  the  nature  of  the  lesion  may  be  determined. 
The  most  rigid  asepsis  shoukJ  he  observed;  the  gloved  fingers  should 
not  be  introduced  within  the  articulation  and  instruments  having 
come  in  contact  with  the  hands  should  not  enter  the  cavity. 
Sponges  should  be  used  but  once.  If  the  cartilage  is  fractured, 
detached  (partially  or  completely),  folded  upon  itself  or  degen- 
erated it  should  be  removed.  Anchoring  of  the  cartilage  to  prevent 
luxation  should  not  be  attempted  as  the  results  are  not  satisfactory. 
Removal  of  the  cartilage  should  be  accomplished  with  as  little 
trauma  as  possible.  If  other  derangements  are  encountered  within 
the  articulation  they  should  be  corrected.  Following  operation  the 
joint  should  be  immo1)i]ized  and  an  ice  cap  applied  to  the  knee  to 
control  any  traumatic  arthritis  which  may  develop. 

After-Treatment. — The  care  of  the  case  following  non-operative 
reduction  consists  in  immobilizing  the  knee  on  a  posterior  splint  in 
complete  extension.  Elevation  of  the  lower  extremity  and  the  use 
of  the  ice  cap  will  tend  to  control  the  traumatic  reaction.     If  trau- 


FRACTURES   AND    LUXATIONS   OP    SEMILUNAR    CARTILAGES         593 

matic  arthritis  develops  i^iiek's  (extension  sliould  bo  employed. 
Immobilization  should  be  maintained  for  a  period  of  thr(ie  wcM.'ks 
and  the  resumption  of  function  should  be  gradual.  Strain  to 
the  knee  in  the  flexed  or  semi-flexed  position  sliould  be  avoided  for 
three  or  four  months.  If  the  inner  side  of  the  sole  of  the  shoe  is 
built  up  and  the  patient  forms  the  habit  of  "toeing  in"  in  walking, 
much  of  the  strain  will  be  removed  from  the  internal  lateral  liga- 
ment and  thus  the  chances  of  recurrent  luxations  of  the  internal 
semilunar  will  be  reduced.  Following  operation  and  removal  of 
the  cartilage  motion  may  be  begun  at  the  end  of  ten  days  and  the 
patient  may  return  to  work  within  two  weeks  if  there  are  no  com- 
plications. 

Prognosis. — Fracture  or  dislocation  of  a  semilunar  cartilage  may 
occur  only  once  if  proper  immobilization  has  been  carried  out  fol- 
lowing the  accident.  If  on  the  other  hand  function  is  resumed 
immediately  or  as  soon  as  the  traumatic  arthritis  has  subsided,  re- 
currence is  almost  sure  to  follow.  Restoration  of  function  fol- 
lowing operation  is  prompt  and  complete.  The  patient  is  able  to 
resume  his  original  occupation  or  to  follow  the  sport  in  which  the 
injury  was  sustained. 


CHAPTER  XLI. 
FRACTURES  OP  THE  PATELLA. 

Surgical  Anatomy. — The  patella  is  a  sesamoid  bone  developed  in 
the  tendon  of  the  quadriceps  extensor  femoris.  It  is  usually  ossi- 
tiod  from  one  center,  which  makes  its  appearance  about  the  third 
year.  In  rare  instances  it  is  developed  from  two  centers,  laterally 
placed.  The  patella  is  attached  to  the  tubercle  of  the  tibia  by  the 
ligamentum  patellae,  which  maintains  the  bone  at  a  constant  dis- 
tance from  the  tibia.  The  anterior  surface  is  subcutaneous  except 
for  the  prepatellar  bursa  which  is  interposed  between  the  bone  and 
the  skin.  The  patella  is  covered  on  all  sides,  except  the  articular 
surface,  by  the  tendon  of  the  quadriceps  which  is  spoken  of  below 
the  bone  as  the  ligamentum  patellae.  In  extension  of  the  knee  the 
articular  surface  of  the  patella  is  in  contact  with  the  trochlear 
surface  of  the  femur ;  in  flexion,  with  the  condyles.  The  lower 
portion  of  the  patella  or  apex  has  attached  to  it,  both  anteriorly 
and  posteriorly,  the  fibres  of  the  ligamentum  patellas. 

The  patella  is  situated  in  two  fibrous  planes;  the  superficial  one 
is  represented  by  the  fascia  lata  covering  the  quadriceps  extensor, 
the  deep  plane  is  the  capsule  of  the  knee-joint.  When  fracture 
occurs  separation  of  the  fragments  does  not  take  place  unless  the 
fascial  planes,  in  which  the  bone  is  situated,  are  torn.  The  func- 
tion of  the  patella  is  to  afford  leverage  to  the  tendon  of  the  quadri- 
ceps, while  acting  across  the  flexed  knee.  The  insertion  of  this 
muscle  is  chiefly  into  the  patellar  ligament,  but  it  should  not  be 
taken  for  granted  that  the  quadriceps  acts  only  through  the  patella, 
since  it  finds  a  broad  insertion  into  the  upper  end  of  the  tibia 
through  the  fascia  lata  and  capsule.  In  instances,  therefore,  in 
which  the  patella  is  fractured  without  tearing  of  the  fasciae  on 
either  side  of  it,  the  patient  still  retains  some  power  in  extending 
the  knee. 

The  mechanism  of  fracture  of  the  patella  has  been  the  subject 
of  considerable  discussion,  and  even  at  the  present  time  differences 
of  opinion  exist  concerning  it.     The  bone  may  be  broken  by  direct 

594 


FRACTURES  OF  THE  PATELLA  595 

violence,  or  by  muscular  action.  When  the  former  is  the  cause 
the  fracture  is  often  stellate  or  irregular  and  comminuted,  depend- 
ing upon  the  nature,  direction  and  degree  of  the  trauma.  In  this 
type  of  fracture  the  lateral  fasciae  are  seldom  torn  and  the  dis- 
placement is  slight.  Fracture  produced  in  this  way  sometimes  re- 
sults in  injury  to  the  underlying  articular  surface  of  the  femur. 
When  fracture  results  from  muscular  action  it  is  caused  by  the 
violent  action  of  the  quadriceps  extensor  on  the  patella  while  the 
knee  is  flexed.  In  this  way  the  patella  is  broken  across  the  con- 
dyles of  the  femur,  and  if  the  muscle  continues  to  act,  the  frag- 
ments are  separated  and  the  lateral  fasciae  torn. 

The  mechanism  of  fracture  of  this  bone,  as  a  result  of  muscular 
action,  may  be  illustrated  by  the  facility  with  which  a  stick  can 
be  broken  across  the  knee  when  it  will  be  impossible  to  part  this 
same  stick  by  simple  traction  and  counter-traction  in  its  long  axis. 
If  a  blow  is  sustained  on  the  flexed  knee  (either  by  a  moving  object 
or  in  a  fall)  while  the  muscle  is  contracting,  the  fracturing  effect 
of  the  muscular  pull  is  greatly  increased.  The  upper  end  of  the 
bone  is  fixed  by  the  quadriceps  and  the  lower  end  by  the  liga- 
mentum  patellae,  while  the  middle  of  the  posterior  surface  is  the 
only  part  of  the  articular  face  in  contact  with  the  femur  during 
flexion.  The  distribution  of  these  three  forces  explains  the  man- 
ner in  which  the  patella  may  be  snapped. 

Fracture  of  the  patella  nearly  always  enters  the  knee-joint,  but 
when  confined  to  the  lower  portion  of  the  apex  of  the  bone,  which 
is  covered  by  the  patellar  tendon,  the  joint  is  not  necessarily  opened. 

Etiology. — Transverse  fracture  of  the  bone  is  most  common,  while 
the  comminuted  form  is  next  in  order  of  frequency.  Over  four- 
fifths  of  all  fractures  of  the  patella  are  in  the  lower  half  of  the 
bone.  This  accident  occurs  more  often  between  the  ages  of  thirty 
and  forty,  and  is  three  times  as  common  in  males.  Muscular  action 
is  probably  responsible  for  more  cases  than  is  direct  violence,  al- 
though a  combination  of  these  two  elements  is  not  at  all  uncommon. 

Symptoms. — Local  pain  is  constant,  with  partial  or  complete  loss 
of  extension  at  the  knee.  The  patient  is  sometimes  able  to  walk 
backward  by  dragging  the  foot  and  keeping  the  knee  hyperex- 
tended.  If  weight  is  put  upon  the  leg,  with  the  slightest  degree 
of  flexion  at  the  knee,  the  lower  extremity  buckles  and  the  patient 
falls.  The  condition  is  usually  simple,  although  in  severe  crushing 
or  cutting  injuries  the  fracture  may  be  compound  and  the  joint 


596 


FRACTURES   AND    DISLOCATIONS 


exposed.     Crepitus  may  be  elicited  in  the  absence  of  separation, 
or  if  the  parted  fragments  are  drawn  toward  each  other  and  the 


Fig.  658. — Old  t'l-iu-luri'  ot'  patelhi  with  siciKiriitiou  ul'  I'nigiufiits.  liect-iil,  t'lacture 
of  the  femoral  neck,  which  accounts  for  the  complete  eversion  of  the  entire  lower  e.vtrem- 
ity.  The  front  of  the  knee  looks  outward  instead  of  upward  and  the  depression  between 
tlie  fragments  of  the  patella  is  just  above  the  point  of  the  arrow. 

serrated  surfaces  rubbed  together.  Some  degree  of  separation  is 
usually  present,  which  in  many  instances  can  be  detected  by  in- 
spection alone  if  the  ease  is  seen  before  the  parts  become  exten- 
sively swollen.     It  is  often  possible  to  lay  one  or  two  fingers  in  the 


k'Viga^ 


Fig.  659. — Shows  an  unusual  case  of  fracture  with  wide  separation  of  both  patellre. 
The  fracture  of  the  left  patella  is  of  three  years'  standing  while  that  on  the  opposite  side 
is  two  years  old.  Case  treated  by  the  expectant  method  which  resulted  in  fibrous  union 
with  subsequent  separation  of  the  fragments.  Case  first  seen  by  the  author  three  years 
after  the  first  fracture. 

depression  existing  between  the  fragments.     Swelling  and  disten- 
tion of  the  joint  follow  rapidly,  and  obliterate  the  depression  be- 


FRACTURES   OF   THE   PATELLA  597 

tween  the  fragments  so  that  the  condition  cannot  be  recognized  by 
inspection,  although  there  is  usually  little  difficulty  in  deterrninijjg 
the  deformity  by  palpation.  The  development  of  ecehymosis  witliin 
twelve  or  twenty-four  hours  of  the  injury  is  the  rule.  It  is  usually 
most  pronounced  on  either  side  of  the  patella  corresponding  to  tlie 
positions  of  the  lateral  fascial  tears. 

The  symptoms  of  acute  traumatic  arthritis  generally  supervene 
within  a  few  hours  of  the  injury.  Swelling,  redness,  pain,  tender- 
ness and  distention  of  the  joint  are  present.  When  the  joint  be- 
comes filled,  the  fluid  reaches  the  surface  between  the  fragments 
and  produces  a  prominent  swelling  anterior  to  the  patella.  Dis- 
tention of  the  joint  cavity  causes  the  patient  to  assume  a  charac- 
teristic position  of  slight  flexion  of  the  knee  and  moderate  eversion 
of  the  thigh.  The  later  symptoms  of  fracture  of  the  patella  depend 
largely  upon  the  line  of  treatment  followed.  Pain,  swelling  and 
tenderness  are  usually  not  severe  at  the  end  of  a  week  or  ten  days, 
especially  if  measures  have  been  instituted  for  their  control. 

Bony  union  seldom  occurs  in  cases  which  have  been  treated  by 
non-operative  methods  and  the  amount  of  impairment  in  function 
will  depend  largely  upon  the  length  and  strength  of  the  fibrous 
union.  This  fibrous  tissue  tends  to  stretch  with  the  subsequent 
use  of  the  member,  so  that  it  is  not  uncommon  for  the  patient  to 
present  himself  for  treatment  at  the  end  of  a  year  or  two  because 
of  pronounced  and  increasing  loss  of  function.  The  separation 
between  the  fragments  may  be  four  or  five  inches  or  even  more,  so 
that  the  quadriceps  extensor  can  be  well  contracted  while  the  knee 
is  still  in  a  position  of  semiflexion.  Secondary  separation  of  the 
fragments  is  not  prone  to  occur  if  the  lateral .  fascia  were  untorn 
at  the  time  of  injury.  Fibrous  adhesions  or  bony  union  between 
the  articular  surface  of  the  patella  and  the  femur,  may  so  fix  the 
knee  cap  that  the  thigh  muscle  cannot  move  it,  thus  producing  loss 
of  function  of  an  entirely  different  character. 

Diagnosis. — The  diagnosis  is  based  on  the  history  of  injury  to  the 
knee  followed  by  prompt  loss  of  function  and  other  symptoms  just 
enumerated.  Little  difficulty  should  be  experienced  in  recognizing 
the  condition  by  inspection  and  palpation  regardless  of  whether  or 
not  separation  of  the  fragments  exists.  Even  though  the  bone  is 
superficial  and  easily  palpated,  nevertheless  it  is  advisable  to  have 
an  X-ray  taken  to  accuratelj^  deteraiine  and  record  the  details  of 
the  fracture. 


598 


FRACTURES   AND   DISLOCATIONS 


Treatment. — The  fact  tliat  reduction  of  tlie  separated  fragments 
is  indieatcd  in  tlie  treatment  of  fracture  of  the  patella,  is  uniforndy 
conceded,  hut.  the  proper  method  of  attaining'  iliis  end  has  been, 
and  is,  the  subject  of  nuich  diseussion.  Even  at  the  present  time 
few  surgeons  agree  concerning  the  best  method  of  procedure.  Some 
are  opposed  to  opening  the  knee-joint  as  long  as  there  is  a  fair 
prospect  of  obtaining  some  kind  of  a  functional  result  by  non- 
operative  methods.     Others  take  the  position  that  every  fracture 


Fig.  660. — Shows  tlie  non-operative  treatment,  of  fracture  of  the  patella.  A.  shows 
the  lower  extremity  fixed  on  a  posterior  splint  with  the  knee  in  a  position  of  slight  flexion. 
The  splint  is  a  straight  splint  heavily  padded  opposite  the  knee.  Two  short  splints  are 
secured  to  the  thigh  on  either  side  of  the  quadriceps  to  prevent  contraction  of  this  muscle. 
B.  shows  diagonal  strips  of  adhesive  applied  above  and  below  the  patella  to  approximate 
the  fragments.  C.  shows  lateral  splints  applied.  D.  shows  the  lower  extremity  raised  on 
pillows  to  relax  the  quadriceps. 

of  the  patella  should  be  subjected  to  open  treatment  if  the  general 
condition  of  the  patient  will  permit  of  operation.  Personal  ex- 
perience and  observation  have  indicated  that  b}^  far  the  best  results 
follow  the  more  radical  measures.  It  is  a  well  known  fact  that  ex- 
cellent functional  results  are  sometimes  seen  in  instances  in  which 
wide  separation  and  heavy  fibrous  union  are  present.  But  on  the 
other  hand  the  highest  percentage  of  functionally  perfect  results  is 
seen  in  cases  in  which  accurate  anatomic  reduction  has  been  accom- 
plished.    Conclusive   deductions   cannot,   at  the  present  time,   be 


FRACTURES   OF    THE   PATELLA 


599 


drawn  from  the  statistics  of  operated  cases  because  of  the  widely 
varying  and  sometimes  imperfect  technique  which  has  been  fol- 
lowed by  different  operators.  In  the  author's  opinion,  non-oper- 
ative treatment  is  only  indicated  in  old  and  feeble  persons,  or  in 
cases  in  which  separation  does  not  exist.  The  lack  of  proper  sur- 
gical facilities  and  skill  or  the  presence  of  certain  constitutional 
diseases,  such  as  diabetes,  will  of  course  act  as  contraindications 
to  the  open  treatment.  The  first  indication  in  the  treatment  of 
fracture  of  the  patella,  in  both  the  operative  and  non-operative 
methods,  consists  in  putting  the  lower  extremity   at  rest  and   in 


Fig.    661. — "Shaped"    ham   splint  with   padding   applied   to   posterior   aspect   of   lower 
extremity  and  held  in  position  by  three  strips  of  adhesive  plaster. 

instituting  measures  to  control  the  traumatic  arthritis.  The  lower 
extremity  should  be  placed  upon  a  jDOsterior  splint,  which  is  secured 
in  position  by  bandages  and  strips  of  adhesive  as  shown  in  Fig. 
660.  A  snug  bandage  should  cover  the  knee  to  control  the  swell- 
ing, and  an  ice  cap  to  the  parts  will  be  found  of  great  service  in 
relieving  pain  and  modifying  the  inflammatory  reaction.  If  the 
expectant  method  is  to  be  followed  adhesive  straps  above  and  below 
the  patella  are  diagonally  placed  in  such  a  manner  as  to  draw  the 
fragments  together  (see  Fig.  660).  It  is  useless,  however,  to  at- 
tempt to  approximate  the  fragments  until  the  joint  distention  has 


600 


FRACTURES   AND   DISLOCATIONS 


subsided,  which  will  not  be  sooner  than  one  week  following  the 
injury.  There  is  no  method  of  applying  these  straps,  even  after 
the  fluid  has  left  the  joint,  which  will  accurately  approximate  the 
fragments  if  separation  has  existed,  notwithstanding  statements  to 
the  contrary.  This  fact  may  be  conclusively  demonstrated  by  the 
use  of  the  X-ray  in  any  given  ease  in  which  the  fragments  are 
supposed  to  have  been  reduced.  In  the  rare  instances  in  which 
fracture  has  occurred  without  separation  of  the  fragments,  as  indi- 
cated by  the  X-ray,  this  method  may  be  counted  upon  to  give  a 
good  result.  In  most  cases  of  fracture  of  the  patella  considerable 
separation  will  be  found  after  everything  which  is  possible  in  a 
non-operative  way  has  been  accomplished,  and  we  therefore  turn 
to  the  open  treatment  to  secure  reduction. 

Operative  Treatment. — The  open  treatment  of  fracture  of  the 
patella  is  the  ideal  method,  but  should  not  be  attempted  unless  one 
fully  appreciates  the  untoward  possibilities,  and  is  thoroughly 
equipped  to  carry  it  through.     If  the  cases,  in  which  unsatisfactory 


Fig.    662. 


Fig.    663. 


Fig.   662. — Shows  the  method   of  placing  the  silver  wire  mattress  suture   in   approxi- 
mating the   fragments   in   a  transverse   fracture   of   the   patella. 

Fig.   663. — Shows  a  horizontal  section  of  the  patella  at  the  same  level.     Note  the  rela- . 
tive  distribution  of  cancellous  and  compact  tissue. 

results  have  followed  the  open  treatment,  are  analyzed,  they  will 
be  found  to  have  resulted  from  one  or  more  of  three  conditions, 
namely :  infection,  insecure  fixation  of  the  fragments  and  prolonged 
immobilization  of  the  knee. 

Asepsis  should  be  perfect  in  every  detail  as  described  under 
"Open  Treatment  of  Fractures"  on  page  754.  Infection  follow- 
ing operations  on  the  knee  means  not  only  failure  in  union,  but 
involvement  of  the  knee-joint  which  may  result  in  loss  of  function 
in  the  articulation,  if  not  amputation  or  death.  It  is  common  to 
find  a  clot  of  blood  in  the  joint  behind  the  fracture,  which  should 


FRACTURES   OF    THE    PATEEIA 


601 


be  removed  before  the  fragments  are  brought  together.  It  is  dan- 
gerous to  leave  this  dead  blood  where  it  may  favor  subsequent  sup- 
puration  (see  ''Open  Treatment  of  Fractures,"  page  754).     The 


Fie     664  — Recent  fracture  of   the  patella  with  separation   of  fragments, 
near   as  the  fragments   could  be  brought  together  by  non-operative   methods. 


Fig.  665.— Same  case  after  operation.  A  silver  wire,  mattress  suture  draws  the 
fragments  into  apposition  and  holds  them  firmly  against  the  displacing  action  ot  the 
quadriceps.      Ultimate   result,    complete   restoration   of   function. 

fragments  should  be  accurately  and  firmly  approximated  at  the 
time  of  operation  and  so  fixed  that  separation  cannot  take  place 
during   the    after-treatment.     Wire    properly   placed    is   the    only 


602  FRACTURES   AND   DISLOCATIONS 

iiKitcrial  wliieli  cau  be  counted  on  to  seeiuv  proper  and  permanent 
iiimiohilizatioii.  Absorbable  suture  nuiterial  has  been  strongly  ad- 
vocated and  i^ood  I'esults  may  foUow  its  ('iui)loyiiient ;  but  the  inse- 
curity resulting;-  from  its  softening  and  absorption  before  the  end 
of  tile  third  week  should  condemn  its  use  in  fracture  of  the  patella. 
It  lias  hccii  used  ill  suturing  the  fascia?  covering  the  patella  and  in 
the  repair  of  latci'al  fascial  tears  as  well  as  in  direct  suturing  of 
tlie  bones  through  drill  holes.  Separation  of  the  fragments  is  likely 
to  occur  during  the  second  or  third  weeks,  which  can  only  mean 
failure  in  bony  union  with  the  possibility  of  further  separation 
through  stretcliing  of  the  fibrous  tissue.  Even  if  chromicised  cat- 
gut or  other  absorl)al)l('  material  could  be  counted  on  to  maintain 
reduction  until  bony  callus  relieved  it  of  strain,  we  could  not  rely 
on  the  sutured  fascia  to  withstand  the  pull  of  the  quadriceps  dur- 
ing this  period.  It  is  apparent,  therefore,  that  wire,  securing  a 
tirm  hold  directly  on  the  bony  fragments,  is  the  most  satisfactory 
method  of  fixation.  The  structure  of  the  patella  should  be  remem- 
bered while  securing  the  fragments.  The  wire  should  be  so  placed 
that  it  obtains  its  hold  on  the  compact  shell,  rather  than  on  the 
internal  cancellated  tissue,  which  is  likely  to  give  way  under  strain 
and  allow  the  loop  of  wire  to  tear  out.  This  is  best  accomplished 
by  a  mattress  suture  of  wire  as  described  later  on.  The  more  se- 
cure the  internal  fixation,  the  safer  is  the  early  employment  of 
passive  motion;  and  early  passive  motion  is  most  essential  in  re- 
establishing the  function  of  the  joint.  Its  proper  use  will  be  de- 
scribed in  the  after-treatment.  Loss  of  function  and  "painful 
joint"  sometimes  occur  in  cases  in  which  proper  reduction  and 
bony  union  have  follow^ed  the  injury.  These  conditions  are  almost 
entirely  due  to  the  lack  of  early  passive  motion.  The  joint  should 
be  moved  not  later  than  two  weeks  from  the  time  of  operation,  but 
passive  motion  has  its  risk,  if  fixation  of  the  fragments  is  not  solid, 
and  should  not  be  attempted  without  properly  guarding  the  patella 
from  the  action  of  the  quadriceps. 

The  following  technique  in  operating  on  fractures  of  the  patella 
has  proven  the  most  satisfactory  in  the  author's  hands  and  may 
be  considered  the  procedure  of  preference  in  most  cases.  An  in- 
cision is  made  exposing  the  fragments ;  it  may  be  longitudinal  and 
directly  over  the  fracture  or  of  the  U-shape  commonly  employed 
in  operations  on  the  knee.  With  the  fragments  exposed  and  sepa- 
rated the  clot  Avhich  is  usually  found  behind  the  fragments  is  re- 


FRACTURES   OF   THE    PATEELA 


(m 


moved  with  thumb  forceps.  Bony  contact  is  essential  and  if  fascia 
is  found  covering  one  of  the  fractured  surfaces  (usually  the  lower) 
it  should  be  carefully  removed  before  the  fragments  are  brought 
together.  In  transverse  fracture  of  the  patella  holes  are  drilled 
in  each  fragment  so  that  the  drill  enters  the  anterior  face  of  the 
patella  and  comes  out  on  the  fractured  surface.  Two  such  parallel 
holes  are   drilled  in  each   fragment  so  that  the   openings   on   the 


Fig.   666. 


Fig.    667. 


Fig.  666. — Wired  fracture  of  the  patella  three  years  after  injury.  Function  as 
good  as  before  accident.  Note  silver  wire  which  crosses  line  of  fracture  twice  but  does 
not  enter  joint.      Accident  in   1905;   wire  in  place   at  the  present  time. 

Fig.  667. — Wired  fracture  of  the  patella  two  years  following  accident.  Patient 
failed  to  follow  instructions,  got  out  of  bed  and  walked  about  shortly  after  operation 
with  the  result  that  the  wire  was  broken.  It  held,  however,  snfficientlv  well  to  secure 
a  functionally  perfect  result.  This  case  demonstrates  the  advisability  of  using  heavy  wire 
which  is  as  well  tolerated  by  the  tissues  as  lighter  material.  Compare  this  case  with 
the  on©  shown  in   Figs.   665    and  note  the   size   of   the  wire. 

fractured  surfaces  are  opposite  the  corresponding  openings  of  the 
holes  on  the  other  fragment.  A  heavy  silver  wire  is  then  threaded 
through  these  holes  so  that  the  two  ends  are  above  the  line  of  frac- 
ture (see  Fig.  662).  The  fragments  are  then  drawn  together  until 
they  are  in  firm  apposition  and  then  the  ends  of  the  wire  are 
twisted  together,  cut  off,  and  turned  in  toward  the  bone.  This 
mattress  suture  will  securely  hold  the  fragments  in  simple  transverse 


604  FRACTURES   AND   DISLOCATIONS 

frat'tnre  of  the  patella  and  in  addition  may  be  made  to  work  well 
when  three  fragments  are  i)resent  instead  ol'  two.  In  the 
presence  of-  eomminntion  it  may  be  impossible  to  make  tlie 
mattress  sutnre  hold  beeanse  of  the  breaking  up  of  the  eom])aet 
tissne,  and  wbeji  such  is  the  ease  a  circular  wire  surrounding  the 
eonnniiiiitcd  hoiic  may  serve  the  purpose.  A  speeiallj'  formed  Lane 
plate  has  been  devised  to  be  used  on  the  patella  but  the  nature  of 
the  bone  and  the  difficulty  of  making  the  screws  hold,  results  in 
wire  being  the  material  of  choice  in  the  open  treatment  of  this 
fracture.  AVhen  the  wire  is  placed  there  should  l)e  no  motion  in 
the  fragments  nor  in  the  wire :  in  other  words  the  fixation  should 
be  as  secure  as  possible,  to  obtain  the  best  results.  The  knee  should 
be  flexed  and  extended  before  the  wound  is  closed  to  see  that  the 
action  of  the  joint  does  not  disturb  the  fixation.  The  skin  incision 
is  then  closed  and  a  few  strands  of  silk-worm  are  left  in  the  lower 
angle  of  the  wound  to  allow  the  escape  of  fluids  following  operation. 
If  the  vertical  incision  is  employed  directly  over  the  fracture,  a 
subcutaneous  running  suture  should  be  so  placed  that  it  will  bring 
as  much  of  the  soft  tissues  between  the  fracture  and  the  skin  as 
possible. 

Fracture  of  the  i:>atella  is  sometimes  compound  from  the  first, 
with  the  joint  exposed  and  infected  at  the  time  of  the  accident. 
AVhen  such  is  the  case,  the  condition  of  greatest  importance  is  in- 
fection of  the  knee-joint.  This  is  a  serious  matter  and  if  not  prop- 
erly controlled  iiuiy  necessitate  amputation,  or  may  even  result  in 
death  from  a  general  sei)sis.  The  opeuing  of  tiie  joint  should  be 
increased  in  size  if  not  already  sufficiently  large,  and  the  edges  of 
the  wound  should  be  trimmed  away  until  all  ti-aees  of  crushed  and 
devitalized  tissue  are  removed.  The  joint  should  then  be  irrigated 
with  a  few  gallons  of  warm  physiologic  salt  solution.  In  iriigat- 
inti  the  wound  a  soft  rubl)er  catheter  should  be  used,  and  carried 
to  the  innermost  recesses  of  the  articulation  so  that  the  flow  will  be 
directed  from  the  interior  of  the  joint  to  the  surface.  After  the 
articulation  has  been  thoroughly  washed  out,  the  soft  tissue  should 
be  accurately  approximated  and  the  joint  closed  as  tightly  as  pos- 
sible with  the  idea  of  preventing  subsequent  leakage.  The  cavity 
of  the  knee  is  then  injected  with  Murphy's  Formalin  Glycerine 
solution,  the  patient  put  to  bed,  the  lower  extremity  elevated. 
Buck's  extension  applied  and  an  ice  cap  kept  on  the  knee.  Sub- 
sequent  injections   of   the   formalin   glycerine   solution   are   made 


FRACTURES  OF  THE  PATELLA  605 

according  to  the  amount  of  leakage  througli  the  incision  and  the 
reaction  occurring  in  the  articulation.  This  method  of  treating 
infected  joints,  devised  by  Murphy,  is  productive  of.  such  vastly 
better  results  that  no  other  form  of  treatment  should  be  considered 
until  after  this  has  been  tried.  If  suppuration  of  the  joint  can 
be  avoided  in  this  way,  suturing  the  patella  may  be  done  at  the 
end  of  two  or  two  and  a  half  weeks  when  the  dangers  of  articular 
infection  have  passed. 

Suturing  of  the  patella  immediately  following  the  accident 
should  not  be  done  in  compound  cases.  The  joint  infection  should 
be  treated  first  and  the  fracture  reduced  in  a  secondary  operation. 
If  infection  of  the  joint  cannot  be  controlled  by  the  initial  irriga- 
tion and  subsequent  injection,  it  should  be  opened  and  freely 
drained,  and  under  such  circumstances  approximation  of  the  patella 
will  be  of  little  importance,  since  ankylosis  of  the  knee-joint  will, 
in  all  probability,  be  the  result.  If  the  accident  occurs  in  a  region 
of  the  country  in  which  tetanus  prevails,  the  patient  should  receive 
a  prophylactic  dose  of  anti-tetanic  serum. 

When  operation  is  done  for  the  secondary  separation  which 
sometimes  follows  fibrous  union  the  method  of  procedure  is  similar 
to  that  already  described.  The  fibrous  tissue  between  the  frag- 
ments should  be  excised  and  the  fractured  surfaces  freshened  and 
approximated.  It  may  occasionally  be  necessary  to  lengthen  the 
quadriceps  above  the  patella  to  bring  the  fragments  together. 
When  the  patella  is  attached  to  the  trochlear  surface  by  adhesions 
it  may  be  possible  to  free  it  by  forced  passive  motion  under  anes- 
thesia. If  the  adhesions  are  too  firm  to  be  broken  up  in  this  man- 
ner it  may  be  necessary  to  open  the  joint  and  divide  them  with 
the  scalpel.  If  the  adhesions  are  extensive  and  show  a  tendency 
to  reform,  a  transplanted  layer  of  fascia  lata  may  be  sutured  in 
position  to  cover  the  articular  surface  of  the  patella.  Early  passive 
motion,  repeated  at  regular  intervals,  will  then',  as  a  rule,  result  in 
a  freely  movable  patella  and  good  articular  function. 

After-Treatment. — The  length  of  the  after-treatment  will  vary 
according  to  whether  or  not  the  open  method  has  been  employed. 
If  expectant  treatment  has  been  followed  immobilization  of  the 
knee  is  required  for  from  six  weeks  to  two  months,  after  which 
guarded  passive  motion  is  indicated.  During  the  use  of  the  splint 
the  dressings  should  be  carefully  watched  and  tightened  to  keep 
them  in  proper  position.     The  diagonal  straps  Avhich  tend  to  pull 


606  FRACTrRES    AND    DISLOCATIONS 

the  fragments  together  are  likt'ly  to  beeoiue  hix,  especially  as  the 
joint  distention  subsides.  During  the  first  two  or  three  weeks,  pads 
should  be  kei)t  on  either  side  of  the  quadrieeps  and  lirmly  l);indaged 
in  position  to  prevent  contraetion  of  this  muscle.  Dui'ing  the 
stage  of  artifiiliii'  iiiHjiiiiniation  the  local  ajjplication  of  the  ice-cap 
will  be  found  of  service  in  controlling  the  reaction.  The  lower 
extremity  should  be  elevated  on  an  inclined  plane  to  favor  the  cir- 
culation of  the  i^arts  and  relax  the  extensor  thigh  muscles.  Accu- 
rate approximation  of  tlie  fragments  is  practically  impossible  in 
the  non-oj-xM-ativc  treatment,  as  pi-eviously  stated,  and  during  the 


Fig.  (568. — Method  of  performing  passive  motion  in  the  treatment  of  fracture  of  the 
patella.  The  left  hand  bears  down  on  the  ankle  thus  fle.xing  the  knee  while  the  right 
hand  pushes  downward  on  the  patella  to  relieve  the  fracture  of  the  pull  of  the  quad- 
riceps. 

time  the  joint  is  distended  it  will  be  useless  to  even  attempt  dimin- 
ishing the  degree  of  separation;  when  the  fluid  has  left  the  joint 
the  distance  between  them  may  be  somewhat  decreased  by  the 
proper  application  of  straps.  At  the  end  of  two  months  the  splint 
may  be  discarded  and  the  patient  allowed  to  get  about  on  crutches 
with  some  more  convenient  form  of  joint  immobilization.  A  cast 
of  the  leg  may  be  made,  split  up  the  front  before  thoroughly  dried 
and  removed.  After  the  plaster  is  set  the  cast  may  be  covered  with 
some  durable  material  and  strips  of  leather  with  hooks,  applied  to 
the  edges  on  either  side  of  the  opening.     In  this  way  the  cast  may 


FRACTURES   OF    THE    PATELLA  607 

be  removed  at  night  for  the  purpose  of  massage  and  motion  of  the 
joint.  During  the  day  it  is  worn  and  when  snugly  laced  immo- 
bilizes the  knee  and  protects  the  patella  from  strain.  Motion  of 
the  knee  involving  strain,  such  as  walking  without  splint  or  cast, 
should  be  prohibited  inside  of  from  six  to  eight  months.  Excep- 
tional muscular  strain  should  be  avoided  for  a  year.  If  fibrous 
union  is  heavy  and  short,  the  time  may  be  considerably  shortened. 
If  it  is  weak  and  shows  a  tendency  to  stretch,  the  period  of  fixation 
and  protection  of  the  knee  should  be  increased. 

The  period  of  disability  following  the  open  treatment  is  strik- 
ingly shorter  than  that  just  described.  The  limb  should  be  kept 
on  a  posterior  splint  as  described  in  the  after-treatment  of  un- 
operated  cases.  The  dressings  should  be  removed  at  the  end  of 
two  weeks  from  the  time  of  operation,  and  passive  motion  insti- 
tuted, provided  the  internal  fixation  was  properly  and  securely 
accomplished  at  the  time  the  joint  was  opened. 

The  manner  of  performing  passive  motion  is  of  considerable  im- 
portance :  the  knee  may  be  so  flexed  that  the  entire  strain  of  the 
thigh  muscles  is  thrown  on  the  patella,  or  it  may  be  so  accomplished 
that  the  fracture  is  entirely  relieved  of  the  pull  of  the  quadriceps. 
When  the  knee-joint  has  been  fixed  for  a  period  of  two  or  three 
weeks  and  the  joint  has  suffered  the  inflammatory  reaction  incident 
to  traumatic  arthritis,  it  will  be  impossible  to  accomplish  passive 
motion  without  producing  spasm  in  the  quadriceps,  and  it  is  this 
spasm  which  should  be  guarded  against.  If  the  surgeon  places 
the  lower  extremity  across  his  knee  while  one  hand  grasps  the 
ankle  and  the  opposite  index  finger  and  thumb  are  pressed  into 
the  thigh  just  above  the  upper  border  of  the  patella,  he  will  be  in 
a  position  to  perform  passive  motion  and  still  protect  the  patella 
from  the  spasmodic  action  of  the  quadriceps  (see  Fig.  668).  As 
the  ankle  is  depressed,  thus  flexing  the  knee,  the  opposite  hand 
forces  the  patella  downward  towards  the  knee  and  takes  up  the 
strain  of  the  contracting  extensors  of  the  thigh.  This  is  the  only 
way  in  which  early  passive  motion  can  be  performed  without  risk. 
Slight,  snapping  sensations  are  sometimes  felt  by  the  hand  which 
forces  the  patella  downward,  but  there  is  no  cause  for  alarm  since 
they  are  produced  by  the  breaking  up  of  adhesions  in  the  joint 
which  at  this  time  are  too  imperfectly  organized  to  act  as  serious 
obstacles  to  motion. 

At  the  end  of  eight  or  ten  weeks,  the  patient  is  allowed  to  get 


608  FRACTURES   AND   DISLOCATIONS 

about  without  any  fixation  apparatus.  It  is  well  for  him  to  carry 
a  eaue,  and  favor  the  injuivd  knee  for  another  two  or  three  weeks, 
and  he  should  be  especially  cautioned  against  unusual  and  excessive 
strains  until  four  or  tive  months  have  elapsed  from  the  time  of  the 
injury.  It  is  well  to  have  another  X-ray  taken  at  the  end  of  three 
months  to  determine  the  presence  of  bony  union.  The  heavier  the 
union,  the  less  caution  is  necessary. 

Prognosis. — Tlie  restoration  of  function  following  fracture  of  the 
l)atella  is  a  variable  (juantity.  Fibrous  union,  even  to  the  extent 
of  two  or  three  inches,  does  not  necessarily  indicate  that  the  pa- 
tient may  not  enjoy  most  excellent  function.  On  the  other  hand, 
accurate  reduction  and  firm  union  does  not  necessarily  indicate  that 
the  knee  will  be  restored  to  its  original  usefulness.  The  percentage 
of  functionally  perfect  results,  however,  is  much  higher  in  cases 
in  which  bony  union  is  present.  In  the  ordinary  fractured  patella 
we  can  hardly  expect  complete  restoration  of  function  with  any 
form  of  non-operative  treatment.  The  power  of  extension  is  likely 
to  be  decreased,  and  the  action  of  the  joint  impaired,  although  it 
is  not  uncommon  to  find  complete  flexion  possible.  "Wlien  fibrous 
union  occurs,  it  will  be  impossible  to  state  whether  this  union  will 
be  heavj',  strong  and  efficient,  or,  on  the  other  hand,  thin,  weak 
and  permitting-  of  subsequent  separation  of  the  fragments.  Weak- 
ness and  painful  joint  are  common  secpielffi. 

The  results  following  the  open  treatment  are  vastly  better,  pro- 
vided the  three  requisites  previously  mentioned,  are  observed, 
namely :  avoidance  of  infection,  secure  internal  fixation  of  the  frag- 
ments and  early  and  persistent  passive  motion.  Under  such  cir- 
cumstances the  usual  result  is  complete  and  permanent  restoration 
of  function,  together  with  absence  of  pain  in  the  articulation. 


CHAPTER  XLII. 

DISLOCATIONS  OF  THE  PATELLA. 

Surgical  Anatomy. — There  are  a  few  anatomical  facts  bearing 
directly  on  dislocations  of  the  patella,  to  be  taken  up  at  this  time 
without  entering  into  the  details  of  the  knee-joint,  which  were 
considered  under  fractures  of  the  patella.  The  pull  of  the  quadri- 
ceps is  upward  and  in  a  direction  parallel  with  the  long  axis  of  the 
femur.  The  ligamentum  patellae  lies  in  the  long  axis  of  the  tibia 
and  since  the  axis  of  the  tibia  is  not  the  same  as  that  of  the  femur 
it  will  be  apparent  that  the  pull  of  the  quadriceps  (with  the  leg 
extended),  is  not  in  line  with  the  long  axis  of  the  ligamentum 
patellae.  It  is  evident,  therefore,  that  when  the  quadriceps  eon- 
tracts  it  not  only  pulls  the  patella  upward  but  also  tends  to  displace 
it  outward.  This  tendency  toward  outward  displacement  of  the 
patella  is  normally  counteracted  by  the  outer  lip  of  the  troch- 
lear surface  of  the  femur  and  the  attachments  of  the  capsule 
and  fascia  lata.  When  the  capsule  and  fascia  lata  internal 
to  the  patella  are  lax,  or  when  the  outer  lip  of  the  trochlea  is  not 
sufficiently  prominent,  the  bone  may  be  displaced  outward  on  vio- 
lent contraction  of  the  extensors  of  the  thigh.  The  angle  at  which 
the  tibia  joins  the  femur  varies  considerably  in  different  persons. 
It  is  usually  greater  in  women  because  of  the  proportionately 
broader  pelvis  and  greater  divergence  of  the  femora.  The  angle 
is  greater  in  short  stocky  persons  than  in  those  of  tall  and  slender 
stature.  If  the  knee  be  fully  extended  and  the  quadriceps  relaxed 
the  patella  will  be  found  quite  freely  movable  from  side  to  side 
as  well  as  vertically.  If  the  lower  extremity  be  kept  in  the  same 
position  and  the  thigh  muscles  tightened  the  patella  immediatel.y 
becomes  fixed.  This  is  due  largely  to  the  vertical  groove  in  the 
trochlea  and  the  corresponding  ridge  on  the  articular  surface  of  the 
patella.  It  will  thus  be  seen  that  although  the  quadriceps  has  a 
lateral  displacing  action  on  the  patella,  yet  the  contraction  of  this 
muscle  also  tends  to  prevent  lateral  displacement  (if  the  fascial 
attachments  and  trochlea  are  normal)  by  forcing  the  patella  into 

609 


610  FRACTURES    AM)    DISLOCATIONS 

the  groove  on  the  troehlea.  Tlie  imiseles  and  fascia^  attached  to  the 
bone  often  tend  to  Hx  it  in  disj)laeenient  after  dislocation  has  oc- 
curred. The  patella  may  be  dislocated  in  any  direction  and  is  not 
nnconinionly  found  rotated  on  its  axis.  If  the  patella  is  displaced 
laterally  until  it  clears  the  trochlear  surface,  or  the  bone  is  com- 
pletely rotated  on  its  axis  so  that  the  articular  face  looks  forward, 
the  dislocation  is  said  to  be  complete.  If  portions  of  the  articular 
surfaces  remain  op])osed  or  if  the  bone  stands  on  edge  tlie  condition 
is  incomplete  and  is  spoken  of  as  a  subluxation.  These  distinctions 
are  of  degree  only,  and  are  more  academic  than  practical.  The 
same  may  be  said  of  the  classifications  based  on  the  details  of  the 
possible  positions  occupied  liy  the  patella  during  displacement. 

F  d 


F 


Fig.    t)70.  Fig.    671. 

Fig.   669. — Normal  relations  between  patella  and  lower  end  of  femur. 
Fig.   670. — Patella  luxated  outward.      Most  common  type. 

Fig.   671. — Represents   patella   displaced   outward   and    "on    edge."      Also   rotation   of 
patella  so  that  the  posterior  surface  looks  forward. 

Etiology. — Luxations  of  the  patella  constitute  less  than  one 
percent  of  all  dislocations.  Displacement  may  be  in  any  direction 
although  the  external  lateral  type  is  by  far  the  most  common.  The 
condition  may  be  partial  or  complete.  It  is  more  common  in 
women  than  in  men ;  in  short  persons  than  in  tall.  ]\Iuscular  action 
is  often  responsible  for  this  luxation,  although  it  may  be  caused  by 
direct  violence.  A  combination  of  these  two  elements  is  not  un- 
common. 

Symptoms. — Sharp  pain  occurs  at  the  time  the  bone  is  pulled  or 
driven  out  of  place,  and  unless  spontaneous  reduction  occurs  (which 
is  not  uncommon)  there  will  be  immediate  loss  of  function  with 
deformity  which  can  be  readily  recognized  both  by  inspection  and 
palpation.  Following  the  accident  symptoms  of  acute  traumatic 
arthritis  develop  although  they  are  seldom  as  severe  as  those  accom- 
panying fracture  of  the  patella.  The  deformity  varies  with  the 
type  of  displacement.  Kecurrence  of  luxations  of  the  patella  are 
not  uncommon  and  may  constitute  a  most  annoying  and  disabling 


DISLOCATIONS   OF   THE   PATELLA  611 

condition.  In  many  cases  the  patient  will  know  just  what  [)0,sition 
of  the  knee  or  what  form  of  strain  is  productive  of  the  displace- 
ment, and  is  always  on  his  guard  to  avoid  the  condition  while  using 
the  lower  extremity. 

Diagnosis. — If  the  surgeon  sees  the  condition  prior  to  reduction, 
he  may  recognize  the  displacement  by  the  characteristic  deformity. 
Palpation  of  the  parts  will  readily  determine,  not  only  the  fact  that 
the  patella  is  displaced  but  also,  the  type  of  luxation  present.  In 
instances  in  which  the  dislocation  has  been  corrected  or  spon- 
taneous reduction  has  taken  place,  it  may  be  difficult  to  differenti- 
ate the  condition  from  a  fractured  or  luxated  semilunar  cartilage. 
A  careful  history  and  examination  of  the  parts  will  usually  result 
in  determining  which  of  the  two  conditions  has  occurred. 

Treatment. — As  a  rule,  little  difficulty  is  experienced  in  returning 
the  patella  to  its  proper  position.  The  knee  should  be  maintained 
in  complete  extension,  while  the  thigh  is  flexed  on  the  abdomen  to 
relax  the  quadriceps  extensor.  If  the  patella  does  not  then  slip 
back  into  place  of  itself,  slight  manipulation  will  usually  suffice  to 
reduce  the  luxation.  Before  manipulation  is  attempted  the  sur- 
geon should  have  learned  the  relations  of  the  displaced  bone  by 
palpation,  so  that  he  may  cause  it  to  retrace  the  course  taken  at  the 
time  of  the  accident.  "When  the  patella  is  found  rotated  on  its 
vertical  axis  it  is  particularly  necessary  that  the  surgeon  know  in 
which  direction  rotation  has  taken  place.  This  is  readily  deter- 
mined by  palpation  of  the  muscle  above,  and  the  ligamentum  pa- 
tellse  below.  It  is  extremely  rare  to  encounter  difficulty  in  reduc- 
tion if  the  above  manipulations  be  followed  out,  but  should  such 
occur,  complete  relaxation  of  the  quadriceps  may  be  had  under 
anesthesia.  In  old,  unreduced  dislocations  of  the  patella  reduction 
may  be  impossible  by  ordinary  methods,  and  under  such  circum- 
stances it  may  be  necessary  to  resort  to  open  treatment. 

Operative  Treatment. — Reduction  of  recent  dislocations  of  the 
patella  by  the  open  method  is  rarely  necessary.  In  old  luxations 
and  in  instances  of  recurrent  dislocations  operative  treatment  is 
often  the  only  method  which  will  give  satisfactory  results.  In 
either  of  these  conditions  the  bone  may  be  exposed  by  a  vertical 
incision  or  by  the  usual  U-shaped  incision.  In  old  luxations  it  may 
be  necessary  to  break  up  old  adhesions  and  cut  through  scar  tissue 
before  the  bone  can  be  returned  to  its  original  position. 

A  number  of  methods  have  been  advised  and  employed  for  the 


612  FRACTURES   AND   DISLOCATIONS 

correction  of  recurrent  dislocations.  The  tubercle  of  the  tibia, 
with  its  attached  liiranu'iitiim  patclUi',  may  ))e  chiseled  oft'  and  re- 
attached to  the  til)ia,  internal  to  its  original  position,  so  that  the 
pull  of  the  (juadriceps  is  straightened,  and  the  nniscle  thus  loses 
its  outward  displacing  action  on  the  patella.  Another  method  con- 
sists in  ])Ucation  of  the  internal  portion  of  the  capsule  or  in  the 
repair  of  a  rent,  if  one  exists,  thus  securing  the  inner  border  of 
the  patella  so  that  it  cannot  be  displaced  outAvard  by  the  pull  of 
the  cpiadriceps.  Still  another  method  consists  in  increasing  the 
prominence  of  the  outer  lip  of  the  trochlea  by  dividing  it  from 
the  fenuir  and  displacing  it  forward.  The  first  two  methods  are 
to  be  preferred  to  the  last.  In  any  of  these  operations  the  most 
strict  asepsis  is  demanded,  especially  if  the  joint  is  opened. 

After-Treatment. — Following  reduction,  the  knee  should  be  put 
at  rest  on  a  ham  splint,  and  measures  instituted  for  the  control  of 
the  traumatic  arthritis.  Snug  bandaging,  and  the  use  of  the  ice 
cap  will  usually  be  followed  by  subsidence  of  swelling  within  a 
few  days.  When  the  inflammatory  reaction  has  passed,  the  knee 
should  be  strapped  with  surgeon's  plaster  to  steady  the  patella, 
and  the  patient  should  be  cautioned  to  avoid  unnecessary  strains. 
The  position  of  the  knee  in  which  the  luxation  occurred  is  particu- 
larly dangerous. 

Prognosis. — Dislocations,  resulting  from  direct  violence  are  likely 
to  be  followed  by  complete  restoration  of  function,  unless  the 
trauma  was  severe  and  resulted  in  injury  to  the  joint  greater  than 
that  occurring  in  the  ordinary  patellar  luxation.  Dislocations  re- 
sulting from  muscular  action  are  likely  to  recur  at  some  later  date. 
Recurrent  dislocations  are  usually  followed  by  good  results  if  ap- 
propriately operated.  In  old  unreduced  dislocations  restoration  of 
function  may  be  delayed  or  incomplete  as  a  result  of  articular 
changes  occurring  while  tlie  bone  was  displaced. 


CHAPTER  XLIII. 

DISLOCATIONS  OF  THE  KNEE. 

Surgical  Anatomy. — In  some  of  the  lower  animals  the  knee  is 
composed  of  three  distinct  articulations.  One  between  the  outer 
tuberosity  and  the  outer  femoral  condyle,  another  between  the 
inner  tibial  tuberosity  and  the  inner  condyle  of  the  femur  and  the 
third  between  the  patella  and  the  femur.  In  the  human  knee  we 
have  the  analogues  of  these  three  joints  although  they  are  all 
merged  into  one.  The  crucial  ligament  attached  to  the  inner  con- 
dyle corresponds  to  the  external  lateral  ligament  of  the  inner  articu- 
lation, and  the  crucial  ligament  attached  to  the  outer  condyle  is 
analogous  to  the  internal  lateral  ligament  of  the  outer  articulation. 
The  knee-joint  is  the  largest  and  one  of  the  most  complicated  in 
the  body.  The  proper  apposition  of  the  articular  surfaces  depends 
almost  entirely  on  the  ligaments  holding  the  bones  together,  and 
when  these  structures  are  lacerated  it  will  be  necessary  to  allow 
sufBlcient  time  for  them  to  become  completely  and  firmly  healed 
before  the  joint  is  subjected  to  any  strain  whatever.  The  liga- 
ments binding  the  tibia  to  the  femur  are  the  posterior  ligament,  the 
internal  lateral,  the  external  lateral  (divided  into  two  parts),  the 
capsule  and  the  crucial  ligaments.  The  two  lateral  ligaments  limit 
lateral  motion  when  the  knee  is  in  the  extended  position  but  are 
much  less  effective  in  this  respect  when  the  knee  is  flexed.  In 
the  flexed  position  the  crucials  perform  this  function.  The  pos- 
terior ligament  limits  extension  of  the  knee.  The  anterior  liga- 
ment, however,  does  not  limit  the  flexion  of  the  joint  since  it  has 
no  attachment  on  the  femur.  It  serves  simply  as  the  insertion  of 
the  quadriceps,  the  tonic  action  of  which  muscle,  acting  through 
the  tendon,  helps  to  keep  the  articular  surfaces  opposed  in  what- 
ever position  the  joint  may  be.  The  semilunar  cartilages,  and 
their  ligaments  (the  coronary  and  transverse)  are  described  under 
the  heading  of  "Fracture  and  Dislocations  of  the  Semilunar  Carti- 
lages, ' '  page  587.  The  ligamentum  mucosum  and  alaria  are  simply 
reduplications  in   the   synovial  membrane   and  together   with   the 

613 


G14  FRACXrRES    AXn    DlST,(irATT()XS 

crucials  represent  llic  division  of  the  joint  into  two  lateral  halves, 
])revioiisly  referred  to.  The  bones  entering  into  the  formation  of 
the  knee-joint  are  long,  and  hence  the  leverage  exerted  against 
the  ligaments  of  the  joint  is  considerable.  The  articular  surfaces 
of  the  ti])ia  and  fenmi-  eoiifonn  to  each  other  only  poorly  and  the 


Fi-.    OT-J 


Fijr.  072. — LiKuinents  of  the  knee.  J.L..  Intenial  lateral  ligament;  E.L.,  External 
lateral  ligament;  i'.,  Femur;  T.,  Tibia;  F.  (below),  Fibula;  Con.,  Condyles.  Between 
the  two  condyles  may  be  seen  the  crucial  ligaments. 

Fig.  673. — Ligaments  of  the  knee.  P.,  Patella;  T.,  Tibia;  V.,  Fibula;  L.P.,  Liga- 
mentum  Pat-ellse;  T.T.,  Tibial  Tubercle;  C,  Caiisule. 

burden  of  hob  ling  these  surfacCvS  together  rests  entirely  with  the 
ligaments.  The  strength  of  these  ligaments,  however,  is  such  that 
dislocations  of  the  knee  are  extremely  rare.  It  is  more  common  for 
unusual  strain  to  produce  fracture  than  to  tear  the  ligaments. 
Fracture  produced  in  this  way  most  often  consists  in  the  avulsion 


DISLOCATIONS    OF    THE   KNEE  615 

of  a  small  scale  of  bone  corresponding  to  the  insertion  of  the  liga- 
ments onto  the  tuberosity  of  the  femur  or  tibia.  In  some  instances, 
however,  an  entire  condyle  may  be  broken  off  by  the  pull  of  the 
ligament.  With  the  knees  extended  and  the  heels  together,  the 
legs  are  parallel,  while  the  femora  diverge  to  include  the  pelvis 
between  them  at  their  upper  ends.  It  is  apparent  therefore  that 
the  axes  of  the  tibia  and  femur  are  not  in  the  same  straight  line. 
This  lateral  angle  at  the  knee  results  in  greater  strain  being  thrown 
on  the  internal  lateral  ligament,  when  longitudinal  compression 
stress  is  brought  to  bear  on  the  lower  extremity.  Accordingly  rup- 
ture of  this  ligament  is  more  common  than  rupture  of  the  external 
lateral  ligament.  If  the  ligament  is  torn  between  the  femur  and 
the  semilunar  cartilage,  the  cartilage  will  remain  attached  to  the 
tibia,  which  it  will  follow  in  displacement.  If  the  tear  is  below 
the  cartilage  the  reverse  will  be  true. 

The  most  common  dislocation  occurring  at  the  knee  is  so  slight 
as  to  scarcely  deserve  the  term  of  subluxation.  It  consists  in  a 
tearing  of  the  internal  lateral  ligament  so  that  the  leg  may  be 
deviated  outward  and  the  inner  condyle  and  tibial  tuberosity  may 
be  separated  a  slight  distance.  Dislocations  of  the  knee  are  classi- 
fied according  to  the  direction  taken  by  the  tibia.  Accordingly 
there  are  anterior,  posterior,  internal  and  external  luxations  of  the 
knee.  In  addition  there  is  another  type  of  dislocation  in  which 
the  tibia  is  rotated  on  the  femur. 

The  relation  of  the  popliteal  artery  directly  behind  the  articu- 
lation is  of  importance  as  already  described  under  "Fractures  of 
the  Lower  End  of  the  Femur."  The  popliteal  nerve  situated 
somewhat  more  superficially  in  the  popliteal  space,  and  the  pero- 
neal nerve  passing  from  behind  the  knee  to  the  outer  side  of  the 
leg  where  it  winds  around  the  head  of  the  fibula,  are  sometimes 
injured  in  dislocations  of  the  knee  as  evidenced  by  sensory  and 
motor  disturbances  throughout  their  areas  of  distribution. 

The  most  important  motion  in  the  knee-joint  is  that  of  the  hinge 
type.  In  addition  to  this  there  is  a  slight  gliding  action  between 
the  femoral  condyles  and  the  tibia,  and  when  the  knee  is  flexed 
there  is  a  slight  rotary  motion  between  the  two  bones.  The  hinge 
action  takes  place  between  the  femoral  condyles  and  the  semilunar 
cartilages,  while  the  gliding  and  rotary  motion  is  between  these 
cartilages  and  the  tibia. 

The  antero-posterior  luxations  are  more  often  incomplete  than 


616  FRACTURES   AND   DISLOCATIONS 

eoiiipleti*.  Complete  lateral  luxations  of  the  knee  are  extremely 
rare.  The  most  common  luxation  is  forward,  and  thru  in  order  of 
frequency,  backward,  outward,  inward  and  rotary.  Great  violence 
is  necessary  to  produce  luxation  of  the  knee.  I'robably  the  most 
eouHuon  injury  to  the  knee-joint  consists  in  rupture  of  the  internal 
lateral  ligament  with  temporary  separation  of  the  articular  sur- 
faces on  the  inner  side  of  the  articulation. 

Symptoms. — Tlie  accident  is  almost  invariably  the  result  of  severe 
trauma  and  if  tlie  history  of  the  case  is  elicited  an  idea  of  the 
deg'i-ec  of  violence  applied  to  the  lower  extremity  at  the  time  of  the 
accident  can  usually  be  had.  Pain,  shock  and  loss  of  function  are 
usually  pronounced.  Any  of  the  luxations  occurring  at  the  knee 
may  be  complete  or  incomplete,  simple  or  compound  and  compli- 
cated or  uncomplieated  l)y  injury  to  vessels  and  nerves.  The 
symptoms  will  vary  according  to  the  details  of  the  case.  Abnormal 
mobility  is  present.  In  complete  luxations  the  action  at  the  knee 
is  usually  tiail-like  and  the  percentage  of  cases  in  which  the  con- 
dition is  compound  is  high.  In  a  complete  forward  dislocation  of 
the  knee  treated  by  the  author  amputation  was  necessitated  by  the 
complete  severance  of  the  popliteal  artery,  and  following  the  oper- 
ation the  knee-joint  was  partially  dissected  for  the  purpose  of  ascer- 
taining the  condition  of  the  injured  structures.  The  two  lateral 
ligaments,  the  posterior  ligament  and  the  crucials  were  completely 
ruptured.  The  inner  head  of  the  gastrocnemius  and  the  popliteus 
were  torn  across.  The  femoral  condyles  projected  through  a  large 
rent  in  the  popliteal  space  and  their  lower  surfaces  were  about 
two  and  a  half  to  three  inches  below  the  level  of  the  tibial  articular 
surfaces.  The  popliteal  artery  was  completely  torn  across  and  the 
ends  separated  shortly  above  the  popliteal  notch.  The  popliteal 
and  peroneal  nerves  w'cre  also  completely  divided.  The  semilunar 
cartilages  remained  with  the  tibia.  This  type  of  case  is  extreme 
and  denumds  immediate  amputation  aliove  the  knee. 

It  is  more  common  to  see  an  incomi)lete  dislocation  in  which  a 
portion  of  the  femoral  condyles  remains  in  contact  with  the  tibial 
articular  surfaces.  The  loss  of  alignment  in  the  axes  of  the  femur 
and  tibia  is  apparent.  The  forward  displacement  of  the  tibia  is 
seen  at  a  glance.  The  patella  is  less  i)rominent  than  normal  be- 
cause of  the  forward  displacement  of  the  tibia.  If  the  artery  is 
compressed  or  divided,  loss  of  pulse  and  lowering  of  temperature 
below  the  knee  will  be  noted.     If  the  artery  is  simply  compressed, 


DISLOCATIONS   OF    THE   KNEE  fil  7 

but  not  otherwise  injured,  the  pulse  will  return  with  reduction  of 
the  luxation.  Pain  may  he  intense  if  the  nerves  are  stretched  or 
compressed;  if  divided,  sensory  and  motor  paralyses  will  he  ])resent. 
In  compound  eases  with  laceration  of  the  artery,  hemorrliHge  is 
usually  not  profuse,  strange  as  it  may  seem. 

In  backward  luxations  the  relations  of  the  tibia  and  fciinur  at 
the  knee,  are  reversed.  The  lower  end  of  the  femur  is  prominent 
anteriorly  while  the  posterior  edge  of  the  upper  end  of  the  tibia 
may  be  palpated  posteriorly.  If  the  luxation  is  complete  the  bones 
override  in  a  manner  similar  to  that  described  in  the  anterior  form 
of  luxation.  The  condition  is  uuich  more  likely  to  be  compound 
when  the  luxation  is  complete.  The  femur  may  penetrate  the  skin 
anteriorly  or  the  upper  end  of  the  til)ia  may  be  found  projecting 
through  a  rent  in  the  popliteal  space. 

The  lateral  luxations  usually  consist  of  either  inward  or  outward 
incomplete  displacement  of  the  tibia.  Complete  lateral  luxation 
of  the  knee  is  quite  rare  and  the  complications  accompanying  the 
condition  are  usually  less  important  than  those  occurring  in  the 
antero-posterior  types. 

In  the  rotary  form  of  luxation,  which  is  extremely  uncommon, 
the  tibia  is  seen  to  have  rotated  on  its  axis  so  that  the  normal  re- 
lations between  the  articular  surfaces  are  disturbed.  The  rotation 
is  seldom  more  than  forty-five  degrees  and  is  more  often  outward 
than  inward.  The  axis  of  rotation  may  pass  through  the  outer  or 
inner  tuberosity  or  in  the  region  of  the  tibial  spine.  The  liga- 
mentous structures  ruptured  will  depend  largely  on  the  axis  of 
rotation. 

In  the  different  luxations  occurring  at  the  knee  any  or  all  of  the 
ligaments  binding  the  tibia  to  the  fibula  may  be  ruptured  or  one  of 
their  attachments  avulsed,  according  to  the  nature  and  degree  of 
the  dislocation.  Avulsion  of  the  tibial  spine  has  occurred  in  lieu 
of  rupture  of  the  crucials. 

Traumatic  reaction  is  usually  pronounced  during  the  first  week 
or  ten  days  following  the  accident. 

Function  is  completely  lost  in  all  forms  of  complete  luxations  of 
the  knee.  Active  motion  of  the  leg  is  sometimes  only  partially 
lost  when  the  luxation  is  incomplete. 

Treatment. — Traction  in  the  long  axis  of  the  lower  extremity 
with  coaptation  pressure  on  the  displaced  articular  ends  will  usually 
suffice  to  reduce  the  luxation.     A  fragment  of  bone  such  as  that 


618  FRAPTrRES   AND    DISLOCATIONS 

l^rodueod  by  avulsion  of  the  iiisoi-tioii  of  one  of  tlie  lateral  liga- 
ments, may  lieconic  iiitcrposeil  between  the  ai'tieular  surfaces  or  a 
displaced  sriuilunai'  cartilage  may  act  a.s  an  oljstaeU'  to  reduction. 
Continuous  ti-action  as  exerted  by  Huek's  extension  may  control  a 
tendency  toward  recurrence  of  deformity  and  is  otherwise  of  service 
if  the  traumatic  arthritis  proves  severe. 

Operative  Treatment. — Operation  is  often  indicated  in  cases  in 
which  tile  luxation  is  complete.  If  the  circulation  below  the  knee 
is  destroyed  amputation  sliould  be  performed  at  once.  One  should 
be  absolutely  ])Ositive,  however,  that  such  is  the  case,  before  remov- 
ing the  leg.  Simple  compression  of  the  artery  will  stop  tlie  pulse 
and  circulation  in  the  leg  but  with  reduction  and  removal  of  pres- 
sure will  be  accompanied  by  the  return  of  the  pulse  in  the  dorsalis 
pedis.  It  may  be  possible  in  some  of  the  compound  cases  to 
directly  examine  the  popliteal  artery  through  the  wound  while  the 
patient  is  on  the  operating  table.  When  the  artery  is  divided  it  is 
usually  much  lacerated  and  the  ends  retracted.  In  com])ound 
cases  in  which  the  circulation  is  not  destroyed  the  wound  sliould 
be  thoroughly  cleansed,  the  devitalized  tissues  trimmed  away  and 
divided  structures  approximated.  Reduction  of  compound  cases 
without  these  precautions  is  much  more  likel}^  to  be  followed  by 
infection  and  suppuration.  (See  "Treatment  of  Compound  Frac- 
tures and  Dislocations,"  page  789.)  Open  incision  is  sometimes 
called  for  to  remove  an  obstructing  fragment  of  l^one  or  a  displaced 
semilunar  cartilage  which  interferes  with  reduction.  The  possi- 
bility of  operative  repair  of  ligaments  should  be  given  careful  con- 
sideration in  instances  of  recovery  with  loss  of  lateral  stability  of 
the  knee-joint.  The  lateral  ligaments  are  easily  exposed  through 
lateral  incisions,  but  operation  on  the  crucials  is  a  much  more  dif- 
ficult matter.  The  crucial  ligaments  are  best  exposed  through  a 
U-shaped  incision  dividing  the  ligamentum  patellae.  The  flap  thus 
made  is  reflected  and  the  knee  ilexed,  so  that  the  ligaments  may  be 
seen  in  the  popliteal  notch.  Plastic  operations  may  be  needed  to 
bring  the  ends  of  the  ligaments  together  and  considerable  ditificulty 
may  be  experienced  in  placing  the  mattress  sutures  because  of  the 
narrow^  limits  of  the  popliteal  notch.  A  small  full-curved  needle 
should  be  used.  A  needle  may  be  heated  in  a  flame  and  bent  while 
hot  to  make  the  curve  sufficiently  sharp  to  meet  the  requirements. 
After  repair  of  the  crucial  ligaments  the  knee  should  be  protected 
from  lateral  strain  for  many  months  by  wearing  a  brace. 


DISLOCATIONS    OF    THE   KNEE  6H) 

After-Treatment. — Following  reduction  of  a  disloeation  or  sub- 
luxation of  the  knee  the  lower  extremity  should  be  immobilized 
on  a  posterior  splint,  the  leg  elevated  on  a  pillow  and  carefully 
watched  for  evidences  of  stasis.  If  at  any  time  during  the  after- 
treatment  it  is  positively  determined  that  the  circulation  has  been 
destroyed  the  leg  should  be  amputated.  The  general  condition  of 
the  patient  will  often  require  careful  attention  during  the  first  few 
days  following  the  accident.  If  shock  is  great  appropriate  stimu- 
lants should  be  exhibited  and  when  accompanied  by  much  pain 
opiates  may  be  necessary.  The  joint  should  remain  fixed  for  a 
period  of  three  months  or  more  according  to  the  extent  of  liga- 
mentary  laceration.  Early  use  of  the  knee  will  usually  be  followed 
by  instability  of  the  joint  and  much  loss  of  function.  The  repair 
of  ligaments  is  often  surprisingly  complete  if  the  proper  time  is 
allowed  before  the  joint  is  subjected  to  strain.  Massage,  when  the 
splint  is  removed  and  during  the  time  the  knee  is  immobilized  is  of 
great  service  in  maintaining  the  tonicity  of  the  thigh  and  calf 
muscles. 

Prognosis. — The  outlook  in  complete  dislocations  of  the  knee  is 
not  good  especially  if  the  condition  is  compound.  The  prognosis 
depends  chiefly  on  the  complications,  the  most  important  of  which 
are  injuries  to  the  artery  and  nerves  and  the  exposure  of  the  joint 
to  infection  in  compound  luxations.  If  the  case  is  incomplete  and 
uncomplicated  good  restoration  of  function  is  the  rule,  provided 
sufficient  time  is  allowed  for  the  proper  healing  of  the  ligaments. 
Imperfect  and  incomplete  healing  of  the  ligaments  may  result  in 
loss  of  lateral  stability,  sufficiently  pronounced  to  require  the  use 
of  a  jointed  knee  brace.  Surprisingly  good  function  has  been 
reported  in  a  few  cases  of  old  unreduced  luxations  of  the  knee. 
If  the  knee-joint  becomes  infected  following  a  compound  luxation 
the  prognosis  will  be  that  of  a  septic  arthritis.  In  severe  compound 
cases  death  may  ensue  from  shock,  thrombosis,  embolism,  sep- 
ticemia, etc.,  unless  prompt  and  radical  surgical  measures  are  insti- 
tuted. 


CHAPTER  XLIV. 

IX.IIKMKS  .irsT    ISF.LOW   TIIH    KXEK— FRACTURES   OF 
THE   T1I51A  AM)  EllU'LA   (UPPER  ENDS). 

The  injuries  occurring  in  this  region  of  the  leg  and  to  be  con- 
sidered under  this  heading  are:  fracture  of  the  upper  end  of  the 
tibia  (either  into  or  below  the  knee-joint),  separation  of  the  upper 
tibial  epiphysis,  fracture  of  the  upper  end  of  the  fibula,  separation 
of  the  upper  tibial  epiphysis  and  dislocations  of  the  upper  tibio- 
fibular articulation. 

Surgical  Anatomy. — The  broad,  expanded,  upper  extremity  of  the 
til)ia  which  tonus  tlie  tuberosities,  is  largely  subcutaneous  and  can 
be  readily  palpated  just  below  the  plane  of  the  knee-joint.  The 
inner  tuberosity  presents  a  horizontal  groove  on  its  posterior  aspect 
for  the  insertion  of  a  portion  of  the  semimembranosus.  The  cir- 
cumference of  the  tuberosity  is  taken  up  by  the  attachment  of  the 
capsule  and  the  intei'ual  lateral  ligament.  In  like  manner  the 
circumference  of  the  outer  tuberosity  is  taken  up  by  the  capsule  on 
the  outer  side  of  the  joint,  Init  the  external  lateral  ligameiits  of  the 
knee  are  not  attached  to  this  Ijone  but  to  the  head  of  the  fibula. 
The  posterior  asi)ect  of  the  outer  tuberosity  articulates  with  the 
upper  end  of  the  fibula,  and  half-way  between  the  tibial  tubercle 
and  th(^  tibulai-  head  is  inserted  the  lower  end  of  the  ilio-tibial 
band.  The  upper  end  of  the  tibia  is  composed  of  cancellous  tissue 
which  is  encased  in  a  thin  layer  of  compact  bone.  The  heavy 
comi)act  tissue  of  the  shaft  grows  rapidly  thinner  as  the  upper  end 
of  the  bone  is  approached. 

Fractui'c  of  tlie  ujjper  end  of  the  tibia  is  the  result  of  direct  or 
indirect  vioh-nce,  usually  tlie  former.  The  line  of  fracture  may 
be  vertical,  entei-ing  the  joint  cavity,  or  it  may  be  transver.se  and 
below  the  articulation.  Transverse  fracture  of  the  upper  end  of 
the  tibia  is  usually  the  result  of  dii'ect  violence  and  tlie  displace- 
ment is,  as  a  rule,  not  gi-eat.  The  superficial  position  of  the  bone 
accounts  for  the  frequency  of  compound  fractures  in  this  region, 
especially  when  produced  by  direct  violence.     AVhen  the  fracture 

620 


INJURIES    .JUST    m-AA)W    THE    KNEE 


621 


enters  the  joint  it  is  usually  the  result  of  violent  adduetion  or 
abduction  of  the  leg.  T-fractures  however  are  usually  the  result 
of  violence  transmitted  to  the  upper  end  of  the  bone  in  the  long 
axis  of  the  tibia.  When  this  mechanism  obtains  in  the  i)roduction 
of  fracture  of  the  upper  end  of  the  tibia  the  shaft  is  driven  upward 
into  the  upper  fragment  and  usually  splits  it  into  two  or  more 
pieces.  The  upper  fragment  is  sometimes  extensively  comminuted. 
This  type  of  fracture  is  most  frequently  the  result  of  a  fall  from 


Fig.  674. — Lateral  view  of  the  knee  before  the  epiphyses  have  joined  the  shaft. 
Note  how  the  wpper  epiphysis  of  the  tibia  extends  downward  anteriorly  to  include  the 
tubercle  of  the  tibia.  This  formation  is  spoken  of  as  the  "lipping"  of  the  upper  tibial 
epiphysis. 


a  height  in  which  the  patient  lands  on  the  foot.  In  rare  instances 
the  shaft  may  be  driven  upward  into  the  upper  fragment  without 
splitting  the  latter  and  the  result  is  likely  to  he  impaction  with 
shortening  of  the  leg,  but  no  abnormal  mobility,  crepitus,  etc. 
Most  of  the  fractures  of  the  upper  end  of  the  tibia  entering  the 
joint  cavity  are  accompanied  by  spreading  of  the  tuberosities.  The 
action  of  the  lateral  ligaments  in  producing  fracture  of  the  tuber- 
osities or  of  the  femoral  condyles  has  been  described  under  ' '  Dislo- 
cations of  the  Knee,"  and  again  under  "Fractures  of  the  Lower 


622 


FHACTTRES    AM)    DISLOCATIONS 


End  of  the  Femur."  Fracture  and  avulsion  of  the  spine  of  the 
tibia  due  to  the  ])ull  of  tlie  crueials  is  a  eoniplication  of  disloca- 
tions of  1lu'  knee,  and  has  been  mentioned  under  Ihat  heading. 

The  upper  epiphysis  of  the  tibia  is  ossified  from  a  single  center 
which  makes  its  apiicarance  soon  after  birth  and  joins  the  shaft 
at  about  the  Iwciitictti  year.  The  epiphyseal  cartilage  corresponds 
roughlx'  1()  a  hdi'izoiital  i>!aii('  about  one  inch  below  the  top  of  the 
bone.  Anteriorly  liowcxcr  it  clii)s  downward  as  it  approaches  the 
anterior  liorder,  to  pass  under  the  tibial  tubercle.  A  not  uncom- 
mon anetnaly  is  for  the  tibial  tuliei-ele  to  be  ossified  l)y  a  separate 


Fig.    675. 


Fig.    676. 


Figs.  675  and  676. — An  anomaly  in  the  ossification  of  the  upper  end  of  the  libia 
which  is  likely  to  be  mistaken  for  fracture  of  the  tibia.  A  close  examination  of  an 
X-ray  plate  (not  print)  will  show  the  supposed  fragment  to  be  surrounded  by  a  layer 
of  compact  tissue  and  the  contour  of  ossicle  does  not  correspond  to  the  portion  of  the 
tibia  from  which  it  is  supposed  to  have  been  broken  off.  Moreover  this  type  of  anomaly 
is   almost   invariably   bilateral. 


center.  This  downw^ard  extension  of  the  epiphysis  to  include  the 
tibial  tubercle  is  of  importance  clinically.  The  quadriceps  extensor 
is  attached  to  the  tubercle  through  the  ligamentum  patellae,  and 
with  violent  contraction  of  this  muscle  the  anterior  part  of  the 
epiphysis  (the  tubercle  of  the  tibia)  may  be  partially  or  completely 
separated  from  the  diaphysis.  Complete  separation  of  the  tibial 
epiphysis  is  an  extremely  rare  condition  but  a  starting  of  the 
tubercle  with  a  corresponding  partial  detachment  of  the  epiphysis 
is  not  uncommon  in  youth. 

The  upper  extremity  of  the  tiljula  does  not  enter  into  the  forma- 


INJURIES    JUST    BET.OW    THE    KNEE 


62:{ 


Fig.    677. 

Fig.    677. — Vertical  fracture   of  upper   end  of   tibia. 
Fig.    678. — Vertical  fracture  of   upper   end   of  tibia. 


Fig.    679. — Fracture  of   upper   end  of  tibia  involving  the   external  articular   surface. 

Fig.    680. — Splitting  of  upper  end  of  tibia. 

Vertical  fractures  of  the  upper  end  of  the  tibia  such  as  those  shown  on  tliis  page  are 
not  uncommon,  and  if  not  accurately  reduced  considerable  disturbance  in  joint  function 
may  result.      Operative  measures  are  frequently  indicated  to  obtain  the  best  results. 


624  I'HACTrKKS    AND    1)1SI.(K 'ATIOXS 

tion  of  the  kiuH'-JDiiit,  though  thi-  two  external  lateral  liwaments  of 
the  knee  are  attaehetl  to  it.  The  lon^'  head  of  the  hieeps  (outer 
luiiiisli'iii^-  luusele)  is  inserted  around  the  base  of  tlie  styloid 
j)roeess,  and  the  attaehnients  of  tlie  soh'us.  i)eroneus  lon.i^rus  and 
extensor  longus  di,uitoi'uin  are  eontiimed  ni)\\ai'd  from  the  shaft 
onto  the  ui)|)er  cxtri'iuity  of  the  bone.  'I'his  epiph.ysis  of  the  fibula 
l)egins  to  os.sify  about  the  foui-th  yeai-  and  joins  the  shaft  at  about 
the  twenty-tifth.  A'iolent  eontraction  of  tlie  bleeps  is  known  to 
ha\('  caused  fraetuiT  of  the  ui)per  end  of  llie  libiila.  oi'  sepai'ation 
of  the  epipliysis,  and  atlduetion  of  the  leg  has  [)iH)tluced  tlie  same 
result  tlirough  the  pull  of  the  external  lateral  ligaments.  Fracture 
of  the  upper  end  of  tlie  liluda  just  bt'low  the  head  of  the  bone  is 
usually  the  result  of  direct  violence.  Occasionally  it  aeconi))anies 
fracture  of  the  upper  end  of  the  tibia. 

The  upper  tibio-libular  articulation  is  a  simple  arthrodial  joint 
with  very  limited  motion.  The  articular  surfaces  entering  into  its 
formation  are  flat  and  the  integrity  of  the  joint  depends  entirely 
on  tlie  strength  of  tlie  ligaments  holding  the  two  bones  together. 
Tliis  joint  possesses  an  anterior  and  a  posterior  ligament  which  are 
thickenings  in  the  capsule  surrounding  the  articulation.  Anterior 
and  posterior  displacements  are  prevented  as  long  as  the  force  is 
not  sufficient  to  rupture  these  ligaments.  Upward  displacement 
is  prevented  not  only  by  these  ligaments  but  by  the  interosseous 
memliraiie  and  tlie  lower  tibio-fibular  articulation.  The  importance 
of  dis])lacements  of  the  upper  end  of  the  fibula  depends  mainly  on 
the  fact  that  the  peroneal  nerve  winds  around  the  neck  of  the 
bone  and  may  be  injured  with  direct  violence  to  the  outer  side  of 
the  leg,  or  when  the  head  of  the  fibula  is  luxated.  This  nerve  can 
be  felt  beneath  the  skin  behind  the  tendon  of  the  biceps.  It 
passes  between  the  tendon  of  the  biceps  and  the  outer  head  of  the 
gastrocnemius  and  then  winds  around  the  neck  of  the  fibula.  It 
passes  forward  to  join  the  anterior  tibial  artery  and  gives  off 
branches,  as  it  passes  down  the  front  of  the  leg,  to  supply  the 
extensors  of  the  foot.  Injury  to  this  nerve  is  accompanied  by  foot 
drop. 

Etiology, — Fi'actures  of  llie  upper  ends  of  the  tibia  and  fibula  are 
usually  due  to  direct  violence.  Forcible  adduction  or  abduction 
of  the  leg  may  result  in  fracture  of  the  tuberosities.  Violence 
transmitted  in  the  axis  of  the  leg  may  produce  fracture  of  the 
upper  end  of  the  tibia  and  fibula,  although  all  forms  of  indirect 


INJIJKIES    .MIST    15Ely()W    TJIE    KNEE  625 

violence  are  more  likely  to  produce  fracture  below  the  middle  of 
the  shaft. 

Symptoms. — Because  of  the'  variety  of  fractures  which  occur  in 
this  region,  the  symptoms  seen  in  different  cases  vary  considerably. 
The  swelling  and  deformity  which  accompany  simple  transverse 
fracture  of  the  upper  end  of  the  tibia  may  be  remarkably  slight. 
I  have  seen  a  number  of  cases  suffering  from  this  type  of  fracture 
in  which  the  patient  was  able  to  bear  weight  on  the  leg.  The  dis- 
ability, however,  is  usually  complete.  Abnormal  mobility  is  almost 
invariably  present  although  impaction  of  the  lower,  into  the  upper 
fragment,  may  result  in  the  leg  being  quite  firm.  AVhen  the  frac- 
ture is  of  the  T-type  or  in  instances  in  which  one  of  the  tuberosities 


Fig.    681. — Fracture  of  upper  end  of  tibia.      Note  thickening  at  point  indicated  by  arrow. 

is  broken  off,  articular  distention"  and  traumatic  arthritis  develop 
rapidly.  Under  these  circumstances  the  lateral  stability  of  the 
knee  is  usually  lost  and  abnormal  lateral  mobility  is  apparent  as 
soon  as  the  parts  are  manipulated.  The  leg  may  be  adducted  or 
abducted  to  an  abnormal  degree  and  this  maneuver  usually  pro- 
duces crepitus.  In  T-fracture  of  the  upper  end  of  the  tibia  or  in 
fracture  of  one  of  the  tuberosities,  the  tuberosities  may  be  spread 
to  such  an  extent  that  the  condition  is  readily  recognized  by 
inspection  alone.  (See  Figs.  681  and  682.)  The  parts  below  the 
knee  are  tender  and  painful.     Fracture  in  this  region,  due  to  direct 


626  FKACTrRES    AXn    DISI.OCWTIOXS 

violence,  is  often  oomjiound  and  il'  tlu-  lino  of  fracture  enters  the 
joint  it  may  be  followed  by  suitpurative  arthritis. 

Avulsion  of  tlic  tubercle  of  the  tibia  is  accompanied  by  a  more  or 
less  upward  displaeeinent  of  the  patella  accordino;  to  the  extent  of 
teariuii-  in  the  latei'al  expansions  of  the  aponeurosis  of  the  (puidri- 
ceps  extensoi-.  Tlic  loose  detached  fragment  can  be  palpated 
without  ditificulty  unless  the  swelling  is  intense.  Tlie  liganientum 
patella'  is  abnornudly  lax.     Kupture  of  the  patellar  ligament  gives 


Fig.  682. — Longitudiiinl  fracture  of  the  upper  end  of  the  right  tibia.  Tuberosities 
spread  so  that  finger  may  be  pressed  into  external  articuUir  cavity  just  above  prominence 
indicated  by  arrow.  Such  a  fracture  will  interfere  with  the  use  of  the  knee  joint  unless 
the  fragments  are  brought  together  and  held  in  place.  Operation  is  usually  necessary 
in  this  type  of  case  to  secure  the  best  results. 

a  similar  symptom-complex  except  for  the  absence  of  the  detached 
fragment  of  the  tubercle. 

Separation  of  the  upper  tibial  epiphysis  is  attended  by  symptoms 
similar  to  fracture  in  this  region.  The  epiphysis  may  be  displaced 
in  any  direction.  The  crepitus  produced  by  manipulation  is  soft 
and  cartilaginous.     The  condition  is  extremely  rare. 

Fracture  or  epiphyseal  separation  of  the  upper  end  of  the  fibula 
is  accompanied  by  local  tenderness  and  pain  especially  when  the 
leg  is  used.  It  is  often  possible  to  move  the  head  of  the  bone  about. 
Crepitus  is  usually  elicited  without  difficulty.     If  the  fracture  is 


INJURIES    JUST    BELOW    THE   KNEE  627 

through  the  tibio-fi})ular  articulation  or  below  it,  pressure  on  the 
shaft  of  the  bone,  in  the  middle  of  the  leg',  will  produce  pain  at  the 
seat  of  fracture.  Injury  to  the  peroneal  nerve  will  b(^  productive 
of  characteristic  symptoms  in  motion  and  sensation  throughout  the 
distribution  of  the  nerve.  In  luxations  of  the  fibular  head  the 
upper  end  of  the  bone  is  more  prominent  than  normal  and  its  dis- 
placement either  forward  or  backward  is,  as  a  rule,  easily  recog- 
nized. 

Injuries  to  vessels  and  nerves  are  not  as  common  in  this  region 
of  the  leg  as  they  are  in  fractures  of  the  lower  end  of  the  femur  but 
when  they  do  occur  the  same  train  of  symptoms  will  become  mani- 
fest. 

Diagnosis. — There  is,  as  a  rule,  little  difficulty  in  recognizing 
fracture  in  this  region.  A  simple  transverse  break,  however,  just 
below  the  tibial  tuberosities,  may,  in  rare  instances,  be  difficult 
to  determine  without  the  aid  of  the  X-ray.  In  the  exceptional 
cases  in  which  the  shaft  is  impacted  into  the  upper  fragment  with- 
out splitting  the  latter,  abnormal  mobility  may  be  absent,  but  the 
condition  should  be  recognized  by  the  shortening  of  the  leg,  and 
in  some  instances  there  will  be  sufficient  angular  deformity  to  indi- 
cate the  nature  of  the  lesion.  The  X-ray  is  of  the  greatest  value 
in  determining  the  nature  of  the  injury  in  the  exceptional  cases 
in  which  the  physical  signs  are  indefinite. 

When  the  upper  end  of  the  fibula  alone  is  fractured  the  patient 
may  be  able  to  get  about,  though  the  use  of  the  member  entails  more 
or  less  swelling  and  pain.  This  fracture  has  not  infrequently  been 
overlooked  in  spite  of  the  fact  that  pressure  in  the  middle  of  the 
shaft  is  productive  of  pain  at  the  site  of  the  lesion,  if  the  fracture  is 
below  or  through  the  upper  tibio-fibular  articulation.  If  the  frac- 
ture is  above  this  level  it  should  be  recognized  by  direct  palpation. 

Treatment. — The  desiderata  in  the  treatment  of  these  fractures 
are:  reduction  of  deformity,  immobilization  of  the  fragments  and 
restoration  of  function  after  the  fragments  have  united.  The 
details  of  treatment  will  vary  with  the  type  and  severity  of  the 
fracture.  In  a  simple  transverse  fracture  of  the  upper  end  of 
the  tibia,  deformity  is  often  slight  and  reduction  easy.  Strong 
traction  on  the  leg  with  direct  pressure  over  the  displaced  frag- 
ment will  usually  effect  reduction.  The  fragments,  however,  are 
often  so  well  apposed  that  nothing  in  the  way  of  treatment  is  indi- 
cated aside  from  fixation.     The  lower  extremitv  should  be  immo- 


628  FRAPTURES    AND    DlSIiOCATIONS 

bilizml  on  a  lony  posterior  splint  extcndinp;  from  jusi  nbovo  the 
lit'cl  to  a  ])oint  a  short  distance  below  the  biittoek.  'I'lie  re<;ulation 
ham  sjjliiit  iua\'  I'e  used  or  cue  may  he  iiuuh'  ot"  plaster.  'The  knee 
sliould  be  tixed  in  a  i)ositii)n  just  short  of  complete  extension  and 
the  padding  einpU)yed  shouM  lie  so  disposed  as  to  eveidy  and  tirndy 
support  the  lower  exti'emity  throughout  the  length  of  the  splint. 
If  there  is  any  tendency  for  the  foot  to  be  rotated  inward  or  out- 
ward the  si)lint  should  include  the  foot.  Tins  may  be  accomi)lislied 
by  a  posterioi-  plaster  splint  extendini^-  downward  to  include  the 
heel  and  sole  of  the  foot.  The  same  result  uuiy  be  hail  by  means 
of  a  long  plaster  stirrup  extending  well  up  onto  the  thigh,  or  the 
long  side  T-splint,  similar  to  that  used  in  fractures  of  the  hip,  may 
be  employed.  AVhichever  splint  is  used  the  means  of  securing  it  in 
position  will  be  found  in  adhesive  strips  and  bandages.  In  cases 
in  which  the  traumatic  reaction  is  severe,  and  rapid  in  onset,  it 
may  be  advisable  to  postpone  manipulation  of  the  parts  until  it  has 
subsided.  This  is  }>articularly  true  when  the  fracture  has  entered 
the  knee-joint  with  the  development  of  a  traumatic  arthritis. 
When  the  fracture  enters  the  joint  cavity  the  correction  of  deform- 
ity and  maintenance  of  the  fragments  in  proper  reduction  is  usually 
nuicli  more  difficult  than  in  simple  transverse  fracture.  In  a 
T-fracture,  or  breaking  off  of  one  of  the  tuberosities,  an  attempt 
should  be  made  to  force  the  fractured  surfaces  together  so  that 
the  articular  surfaces  on  the  head  of  the  tibia  will  be  in  proper 
relation  with  the  condyles  of  the  femur.  This  is  often  a  difficult 
matter  and  requires  skillful  manipulation.  If  one  of  the  tuber- 
osities has  been  broken  off,  lateral  deviation  of  the  leg  to  the 
opposite  side  will  often  facilitate  reduction  of  the  displaced  frag- 
ment. If  the  fracture  is  of  the  T-type  with  separation  of  the 
tuberosities,  adduction  or  abduction  of  the  leg  will  accomplish 
nothing.  Under  these  circumstances  strong  traction  in  the  axis  of 
the  tibia  will  lie  necessary  while  the  tuberosities  are  forced 
together  by  lateral  pres.sure.  In  some  cases  it  will  be  impossible  to 
approximate  the  tuberosities  in  this  manner,  and  in  other  instances 
the  tendency  to  recurrence  of  deformity  may  be  so  great  that  the 
tuberosities  separate  as  soon  as  traction  and  lateral  pressure  are 
removed.  Under  these  circumstances  open  reduction  either  with 
or  without  internal  fixation  is  indicated.  Not  infrequently  a 
loose  fragment  of  bone  between  the  tuberosities  acts  as  an  obstacle 
to  reduction   and    will    require   removal   before  the   fragments   can 


INJURIES    .IITST    BELOW    TIIK    KNKE 


629 


be  brought  into  proper  position.  Tn  instances  in  wiiich  the  shaft, 
has  been  driven  into  the  ui)per  end  of  the  tibia  with  extensive 
comniinution,  the  destruction  of  bone  may  be  so  great  that  it  is 
impossible  to  restore  the  original  contour  of  the  upper  extremity 
of  the  bone.  In  this  type  of  case  continuous  traction  by  means 
of  Buck's  extension  will  often  accomplish  more  than  any  other 
method.  AVhen  extension  is  employed  for  this  purpose  the  lower 
extremity  should  be  so  fixed  to  the  splint  that  the  traction  does  not 
pull  the  axes  of  the  tibia  and  fibula  into  the  same  straight  line, 
otherwise  the  normal  lateral  angle  of  the  knee  will  be  obliterated. 

What  has  been  said  of  the  treatment  of  fracture  of  the  upper 
end  of  the  tibia  applies  equally  well  in  separation  of  the  upper 
tibial  epiphysis. 

Avulsion  of  the  tibial  tubercle  in  the  adult  usually  calls  for 
operative  treatment  to  secure  the  fragment  in  proper  position. 
Straps  of  adhesive  above  the  patella  to  prevent  upward  displace- 
ment, and  bandages  about  the  upper  part  of  the  leg  to  force  the 
fragment  home  are,  as  a  rule,  only  partially  successful.  If  there 
has  been  little  or  no  upward  displacement  of  the  fragment  non- 
operative  measures  will  probably  produce  the  desired  result. 
Starting  of  the  tubercle  as  an  epiphysis  is  usually  not  attended  by 
much  displacement  and  the  treatmeiit  will  consist  of  fixation  and 
rest  until  the  loosened  portion  of  the  epiphysis  has  become  firmly 
fixed  again. 

In  luxations  of  the  head  of  the  fibula,  pads  may  be  so  placed,  and 
held  in  position  by  straps  of  adhesive  plaster,  as  to  prevent  recur- 
rence of  deformity.  The  lower  extremity  should  be  immobilized 
for  three  or  four  weeks,  and  in  backward  luxations  the  condition 
should  be  treated  with  the  knee  semiflexed  to  relax  the  pull  of  the 
biceps.  If  these  measures  are  not  effective  in  maintaining  reduc- 
tion, or  if  evidences  of  nerve  laceration  are  present,  operation  is 
indicated.  Operation  is  also  indicated  in  fractures  of  the  fibular 
head  with  upward  displacement  of  the  fragment. 

Operative  Treatment. — In  cases  of  simple  transverse  fracture  of 
the  tibia  below  the  knee,  with  good  reduction,  operative  interven- 
tion oft'ers  nothing,  but  when  the  fracture  enters  the  joint  cavity  it 
may  become  necessary  to  cut  down  on  the  fragments  to  restore  the 
articular  surfaces  of  the  knee-joint  to  their  normal  relations. 
Cases  in  which  the  tuberosities  cannot  otherwise  be  brought  back 
into  proper  relation,   or  in  w^hich  recurrence   of  deformity  takes 


630  FRACTURES   AND    DTSLOCATTONS 

place,  should  be  operated  upon.  If  two  longitudinal  incisions  are 
made,  one  on  the  inner  and  the  otlicr  on  tlic  oultM-  side  of  the  joint, 
the  fraijnient.s  ni;iy  he  directly  niaiii|)ul;i1e(l  and  reduction  effected.' 
If  a  solid  engairement  can  be  obtained  between  tlieni,  tlie  incisions 
may  be  closed  and  splints  ai>plied.  If  a  tendency  toward  tlie 
recurrence  of  deformity  is  manifest  the  fragments  should  be 
secured  by  some  method  of  internal  fixation.  Non-absorbable 
materials  should  not  be  used  if  the  fracture  is  compound.  In  a 
number  of  cases  of  T-fractures  the  author  has  found  the  following 
procedure  satisfactory  :  two  holes  are  drilled  transversely  tlirough 
the  tuberosities  after  they  have  been  forced  together,  and  a  lieavy 
silver  wire  is  threaded  through  the  holes  and  the  ends  tightly  twisted 
together,  tlnis  maintaining  the  fragments  in  proper  position  and 
restoring  the  intra-articular  surfaces  in  their  normal  relations. 
Tliis  method  is  equally  efficient  in  instances  in  which  one  of  the 
condyles  is  broken  oflp  and  displaced.  The  principle  is  the  same  as 
that  already  described  as  "transverse  wiring"  under  the  heading 
of  "Operative  Treatment  of  the  Lower  End  of  the  Femur."  Nails, 
screws,  and  the  Lane  plate  are  at  a  discount  in  this  region  because 
of  the  internal  structure  of  the  upper  end  of  the  tibia  which  is 
composed  of  a  loose  cancellous  tissue.  Compound  fractures  of  the 
upper  end  of  the  tibia  should  be  treated  according  to  the  principles 
laid  down  under  the  heading  of  "The  Treatment  of  Compound 
Fractures"  on  page  789. 

Avulsion  of  the  tibial  tubercle  with  displacement  of  the  frag- 
ment can  seldom  be  reduced  and  maintained  in  proper  position 
without  operation.  The  fragment  may  be  secured  in  place  by 
means  of  a  small  nail  or  it  may  be  sutured  to  the  adjacent  peri- 
osteum and  surrounding  soft  tissues  with  absorbable  suture  material. 
Prol)ably  the  best  method  in  the  adult,  is  to  secure  it  to  the  shaft  by 
means  of  a  loop  of  silver  wire.  The  scale  of  bone  torn  away  may 
be  too  small  to  fix  in  this  manner,  or  instead  of  an  avulsion  there 
may  be  a  rupture  of  the  patellar  ligament,  and  when  either  of  these 
conditions  is  encountered,  the  operation  must  consist  of  suturing 
of  the  soft  tissues  to  properly  anchor  the  ligament.  When  the 
tubercle  is  avulsed  as  an  epiphysis  it  sliould  not  be  sutured  in 
position  witli  anything  except  absorbable  material. 

An  occasion  calling  for  open  reduction  of  a  complete  separation 
of  the  upper  tibial  epiphysis  almost  never  arises.  In  fractures  or 
dislocations  of  the  upper  end  of  the  fibula,  the  condition  most  often 


INJURIES    JUST    BELOW    THE    KNEE  631 

rendering  operation  necessary,  is  injury  to  tlie  peroneal  nerve  as  it 
winds  around  the  neck  of  the  bone.  When  a  portion  of  the  fibular 
head  has  been  displaced  upward  by  the  pull  of  the  biceps,  the 
fragment  should  be  exposed,  replaced  and  sutured  in  position. 
Non-operative  methods  of  correcting  this  displacement  are  usually 
not  successful. 

In  dislocations  of  the  head  of  the  fibula  the  most  prompt  recovery 
and  complete  restoration  of  function  follow  open  reduction,  with 
fixation  of  the  head  in  proper  position  against  the  external  tibial 
tuberosity.  This  may  be  accomplished  by  suturing  the  soft  tissues 
about  the  head  or  by  means  of  a  single  loop  of  wire  passed  through 
the  adjacent  portion  of  the  tuberosity. 

After-Treatment.— The  first  portion  of  the  after-treatment  will 
depend  largely  on  the  intensity  of  the  traumatic  reaction  following 
the  injury  and  whether  or  not  the  knee-joint  is  involved.  When 
the  reaction  is  severe  it  is  often  best  to  postpone  manipulation  of 
the  parts  until  it  has  subsided.  The  lower  extremity  should  be 
treated  on  a  pillow-splint  and  the  member  elevated  to  favor  circu- 
lation. The  ice  cap  will  aid  materially  in  controlling  the  swelling. 
Undue  constriction  of  the  member  should  be  avoided.  With  the 
subsidence  of  swelling,  reduction  should  be  accomplished  by  non- 
operative  methods,  if  possible,  or  with  operation  if  necessary.  At 
the  end  of  ten  days  or  two  weeks  a  permanent  dressing  should  be 
applied.  The  plaster  cast  or  plaster  splints  will  be  found  quite 
satisfactory  in  this  respect.  If  the  plaster  cast  is  used  it  should  be 
split  up  the  front  before  the  plaster  has  set  so  that  it  may  be 
removed  during  the  after-treatment  for  inspection,  massage  and 
passive  motion  of  the  leg.  Repeated  adjustments  will  be  found 
necessary  during  the  after-treatment  to  keep  the  patient  comfort- 
able. Frequent  inspection  of  the  leg  is  necessary  to  recognize  and 
treat  pressure  points  on  the  skin,  should  they  develop.  In  the 
healthy  adult  union  is  to  be  expected  in  an  uncomplicated  case  at 
the  end  of  six  weeks,  but  the  callus  at  this  time  is  too  soft  to  with- 
stand any  considerable  strain.  The  full  weight  should  not  be 
borne  on  the  leg  for  another  month.  Gratifying  results  have  been 
obtained  by  use  of  the  ambulatory  pneumatic  splint  in  simple  frac- 
tures of  this  region.  When  this  splint  is  employed  it  is  often 
possible  to  begin  the  ambulatory  treatment  as  .soon  as  the  acute 
swelling  has  subsided.  In  compound  fractures  of  the  upper  end 
of  the  tibia  recovery  maj"  be  much  delayed  b}^  the  development  of 


632  FRACTURES    AND    DISLOCATIONS 

iK'(_Totic  boiU'  or  arthritis  of  tlic  knee,  rersistnit  diseliarging 
sinuses  call  for  operation  to  remove  the  dead  bone.  Early  guarded 
passive  motion  will  accomplish  a  great  deal  in  the  prevention  of 
permanent  adhesions  within  the  joint  cavity.  Anesthesia  and 
forcible  passive  motion  may  be  indicated  to  break  up  organized 
adhesions  within  the  knee.  Even  arthrotomy  may  be  called  for  in 
instances  in  which  the  adhesions  are  unusuall.>'  strong.  Early 
passive  motion  is  called  for  to  restore  the  function  of  the  knee  but 
the  greatest  care  should  be  exercised  to  avoid  refracture  during 
the  time  the  callus  is  friable.  If  a  firm  grasp  be  taken  of 
the  upper  end  of  the  tibia,  force  may  be  applied  with  much  less 
risk  than  is  the  case  when  the  leg  is  moved  by  the  usual  grip  above 
the  ankle.  The  lower  the  leg  is  grasped,  in  performing  passive 
motion,  the  less  the  surgeon  appreciates  the  leverage  he  is  exerting 
against  the  upper  end  of  the  bone  and  the  articulation.  The  dress- 
ing should  be  renewed  from  time  to  time  to  accommodate  the 
changes  which  occur  with  the  onset  and  subsidence  of  swelling. 
The  older  the  patient  the  longer  the  time  required  for  firm  union 
to  take  place  and  the  more  imperfect  recovery  will  be  in  the  end. 

In  avulsion  of  the  tubercle  of  the  tibia  union  may  be  expected 
within  six  weeks  and  the  member  may  be  actively  used  at  the  end 
of  two  and  a  half  months.  If  the  condition  has  been  treated  by 
non-operative  methods  the  parts  should  be  frequently  inspected  to 
see  that  the  strappings  are  properly  performing  their  function  in 
holding  the  fragment  in  reduction. 

In  separation  of  the  upper  tibial  epiphysis  the  knee  should  be 
immobilized  for  a  period  of  six  weeks  during  the  latter  half  of 
which  time  passive  motion  should  be  performed  at  intervals  of 
four  or  five  days. 

In  dislocations  of  the  upper  end  of  the  fibula  retentive  apparatus 
should  be  kept  in  place  for  about  a  month,  provided  the  luxation 
has  not  been  secured  in  position  by  operation  and  internal  fixation. 
During  this  time  undue  strain  should  be  avoided,  especially  activ- 
ities which  involve  forceful  contraction  of  the  flexors  of  the  leg  of 
which  the  biceps  is  one. 

Prognosis. — The  prognosis  of  fractures  of  the  upper  end  of  the 
tibia  is  very  variable  according  to  the  extent  and  severity  of  the 
lesion.  Simple  fractures  not  produced  by  severe  trauma  are 
usually  followed  by  complete  restoration  of  function.  On  the  other 
hand,  a  severe  compound  fracture  entering  the  knee-joint  may  be 


INJURIES   JUST    BELOW   THE   KNEE  633 

followed  by  infection  of  the  knee-joint  with  .septicemia  and  death. 
Restoration  of  function  in  severe  cases  is  usually  prolonged  and 
seldom  complete.  The  development  of  septic  arthritis  renders  the 
fracture  itself  only  of  secondary  importance.  The  prognosis  fol- 
lowing operative  cases  is  better  than  those  treated  by  non-operative 
methods.  Union  often  takes  place  with  permanent  thickening 
below  the  knee  and  the  motion  in  the  articulation  is  not  infrequently 
restricted. 

The  prognosis  of  avulsion  of  the  tubercle  of  the  tibia  in  the  adult 
is  good  with  proper  treatment;  when  separated  as  an  epiphysis 
the  prognosis  is  equally  good. 

The  prognosis  of  fractures  and  dislocations  of  the  upper  end  of 
the  fibula  is  good,  aside  from  the  injuries  sustained  by  the  peroneal 
nerve.  "When  the  nerve  is  injured  the  outlook  varies  with  the 
degree  of  the  injury  and  the  completeness  of  repair  which  is  pos- 
sible at  operation. 


CHAPTEK  XLV. 

FRACTURES  OF  THE  SHAFTS  OF  THE  BONES 
OF  THE  LEO. 

The  division  of  fractures  of  the  leg  into:  Fractures  of  the  upper 
ends.  Fractures  of  the  shafts  and  Fractures  of  the  lower  ends,  is 
not  a  scientific  classification  of  these  injuries,  yet  it  forms  a  work- 
ing basis  for  their  consideration.  There  is  no  hard  and  fast  line 
to  be  drawn  l)etween  fractures  of  the  shaft  and  fractures  of  the 
extremities.  The  nearer  the  break  is  located  to  the  end  of  the 
bone  the  more  it  assumes  the  characteristics  of  a  typical  fracture 
of  the  extremity. 

Surgical  Anatomy. — The  shafts  of  the  bones  of  the  leg  are  each 
ossified  from  centers  which  make  their  appearances  during  the 
seventh  and  eighth  weeks  of  fcetal  life.  That  for  the  tibial  shaft 
delevops  first.  The  shaft  of  the  tibia  constitutes  the  main  strength 
of  the  leg.  It  is  distinctly  triangular  in  cross-section  and  shows 
three  surfaces  separated  from  each  other  by  three  prominent 
borders.  The  anterior  border  is  subcutaneous  and  may  be  palpated 
from  the  tibial  tubercle  to  the  internal  malleolus.  The  lower  third 
of  this  border,  however,  is  much  less  prominent,  and  is  more  or  less 
obscured  by  the  tendon  of  the  tibialis  anticus.  The  external  border 
is  directed  toward  the  fibula  and  has  attached  to  it  the  heavy 
interosseous  membrane.  The  internal  border  may  be  palpated 
throughout,  though  in  Avell  developed  persons  the  middle  portion 
is  more  or  less  encroached  upon  by  the  bellies  of  the  flexor  muscles 
of  the  foot.  The  internal  surface  of  the  bone  is  subcutaneous  except 
for  the  insertions  of  the  gracilis,  semitendonosus  and  sartorius, 
which  are  attached  to  the  upper  end,  a  short  distance  below  the 
inner  tuberosity.  AVith  the  intense  swelling,  which  so  frequentlj' 
develops  following  fracture,  it  is  hard  to  realize  that  this  portion  of 
the  bone  is  subcutaneous.  The  thickening  is  often  sufficient  to 
obscure  the  outline  and  render  palpation  difficult,  but  it  should 
be  remembered  that  this  infiltration  is  in  the  subcutaneous  tissues 
and  that  gentle,  firm  and  continued  pressure,  with  the  finger  tips, 

o:i4 


FRACTURES   OF    .SHAFTS    OF    THE    BONES   OF    LEG  635 

will  SO  displace  these  fluids  that  the  condition  of  the  hone  may  he 
recognized. 

The  weakest  part  of  the  tibial  shaft  is  at,  and  just  below,  tlie 
junction  of  the  middle  and  lower  thirds,  and  it  is  here  that  fracture 
most  frequently  occurs.  The  shaft  is  composed  of  a  tid)e  of  lieavj' 
compact  tissue  and  the  fractures  occurring  in  this  region  are  clean 
cut  and  show  no  impaction  or  crushing  of  bone  tissue.  Comminu- 
tion is  not  infrequently  seen  and  the  fracture  may  be  multiple; 
but  the  fragments  are  hard  and  the  edges  clean  cut,  and  screws  find 
a  firm  foothold  when  the  Lane  plate  is  employed  to  secure  reduc- 
tion and  immobilization.  The  shaft  of  the  tibia  normally  bows 
slightly  forward  while  the  fibula  bows  a  little  in  the  opposite  direc- 
tion. 

The  shaft  of  the  fibula  is  almost  entirely  surrounded  by  muscles 
which  act  as  cushions  in  the  presence  of  direct  violence.  The  upper 
extremity  and  external  malleolus  are  the  onl}^  portions  of  the 
fibula  which  can  be  satisfactorily  palpated.  The  lower  third  or 
fourth  of  the  external  surface  of  the  bone  may  be  felt  between 
the  peroneus  tertius  anteriorly  and  the  peroneus  longus  and  brevis 
posteriorl5^  The  shaft  of  the  fibula  is  long  and  slender  and  nor- 
mally possesses  a  certain  degree  of  spring  when  compressed  against 
the  tibia.  This  fact  is  of  importance  clinically  since  lateral  pres- 
sure, in  the  presence  of  fracture,  will  detect  an  increase  or  loss  of 
this  spring  as  compared  with  the  opposite  fibula,  even  though  the 
bone  cannot  be  directly  palpated. 

The  shafts  of  the  bones  of  the  leg  are  usually  both  broken, 
though  isolated  fracture  of  either  bone  may  occur.  The  fibula  is 
more  frequently  fractured  than  the  tibia.  AA^hen  both  bones  are 
broken  the  lesion  in  the  fibula  is  usually  at  the  higher  level.  The 
fracture  in  the  tibia  may  be  transverse,  oblique,  spiral,  or  longi- 
tudinal. Spiral  and  oblique  fractures  are  quite  common  below  the 
middle  of  the  shaft  and  are  usually  the  result  of  indirect  violence. 
Transverse  fractures  are  more  common  above  the  middle  of  the 
shaft  and  are  usually  due  to  direct  violence. 

The  upper  posterior  portions  of  the  shafts  of  the  bones  of  the 
leg  are  covered  and  protected  by  the  heavy  calf  muscles,  and  the 
tendo  Achillis  in  the  lower  part  of  the  leg  is  capable  of  breaking 
the  force  of  a  blow,  when  direct  violence  is  sustained  from  behind. 
Anteriorly  the  tibia  has  no  such  protection  but  receives  the  full 
force  of  direct  violence  applied  to  the  shin. 


636 


P^RACTURES    AND    DISLOCATIDXS 


Fig.   683. — Compound    tiM.iuii'    .ii    Imtli    Imiws   of   the    leg.      Note    the   eversion    of    the 
foot  and  comi)are  it    with   tlie  patella   which   is   directed  upward. 


Fig.  G8.5. — Compound  fracture  (jf  Ijoth  bonc-.s  uf  the  leg  with  sliurtening  and  ever- 
sion. Result  of  direct  violence.  Note  the  position  of  the  patella  which  looks  directly 
upward  while  the  foot  is  decidedly  everted.  Lower  end  of  upper  fragment  penetrated 
the  skin  where  the  wound  is  seen  at  "x." 


FRACTURES   OP    SHAFTS   OF    THE    BONES   OF    LEG 


637 


The  subcutaneous  position  of  the  anterior  border  and  internal 
surface  of  the  tibia  accounts  for  the  large  proportion  of  compound 
fractures  in  this  region,  especially  when  caused  by  direct  violence. 
The  direction  of  the  oblique  or  spiral  fracture  is  usually  from 
above,  downward  and  forward. 

Etiology. — Fracture  of  the  shafts  of  the  bones  of  the  leg  is 
rather  a  common  accident  and  results  from  either  direct  or  indirect 


Fig.    686. 


Figs.  686  and  687. — Show  a  simple  fracture  of  both  bones  of  the  leg  in  their  lower 
thirds.  Note  the  inward  falling  of  the  foot,  while  the  position  of  the  knee  is  normal. 
Photographs  taken  a  few  minutes  following  injury. 


violence.  It  is  often  caused  by  a  twist  of  the  leg,  a  fall  from  a 
height,  a  direct  blow  on  the  shin,  or  a  crushing  force,  such  as  being 
run  over  by  a  wagon.  Fractures  of  the  fibula  alone  are  usually  the 
result  of  direct  violence.  Fracture  of  the  tibia  alone  is  almost 
always  the  result  of  direct  violence.  Fracture  of  the  shafts  of 
these  bones  occurs  most  frequently  during  the  fourth,  fifth  and 
sixth  decades.     This  accident  is  the  most  frequent,  occurring  in  the 


638 


FRACTIKKS    WD    DISLOCATIONS 


lowtT  oxtri'iiiity.  nnd   constitutes  jipin'oxitiiatcly   six   jxTi't'iit   of  all 
fractuiH's. 

Symptoms.-^— liiiiiic(li;itc   ami    lota!    loss  of   fiiiictioii    is   the   rule. 


Fig.    688. 


Fig.    689. 

■Figs.  6.SS  and  fiSO.^ — Friictiire  of  botli  hones  of  tlie  leg  near  ,iun<tion  of  lower  and 
middle  thirds,  seen  a  few  minutes  after  the  accident  and  again  four  days  later.  Note 
the  position  of  the  patella  looking  directly  upward  while  the  foot  has  fallen  inward  of  its 
own  weight.  Condition  flail-like.  In  Fig.  689  (same  leg  four  days  later)  the  deform- 
ity has  heen  corrected  and'  the  .sides  of  the  fracture  box,  in  which  the  leg  has  been 
placed,  have  been  let  down  for  inspection  of  the  parts  and  read.justment  of  the  padding. 
Note  the  swelling  of  the  leg  and  the  development  of  blood-blebs  over  the  site  of  fracture. 
The  leg  is  the  most  common  site  for  the  development  of  these  blood-blebs  following  frac- 
ture. The  leg  should  not  be  put  in  a  permaiient  dressing  until  the  denuded  surfaces 
resulting  from   these  blebs   have   thoroughly   healed. 


Paiu,  crepitus,  abnormal  mobility  and  deformity  are  almost  uni- 
formly present.  The  deformity  is  usually  sufficient  for  the  surgeon 
to  recognize  the  condition  by  inspection  alone.     Fracture  at  the 


FRACTURES    OP    SHAFTS    OF    THE    BONES    OF    LEG  689 

usual  site  (near  the  junction  of  the  lower  mikI  middle  tliitnlsj  eoiii- 
raonly  shows  a  downward  and  forward  displaecmcut  of  the  lower 
end  of  the  upper  fragment  with  a  correspondirjg  upward  and  back- 
ward displacement  of  the  lower  fragment.  The  leg  is  usually  fiail- 
like  and  the  foot  falls  either  inward  or  outward  (usually  the  latter), 
according  to  the  position  in  which  the  lower  extrcinity  luipiiens  to 


Fig.  690. — Green-stick  fracture  of  the  tibia  in  a  child  a  few  minutes  following  the 
injury.  Note  the  slight  inward  bowing  of  the  skin.  In  this  case  it  was  possible  to 
slightly  spring  the  tibia  inward  by  lateral  pressure.      Arrow  indicates  site  of  fracture. 


Fig.  691. — Double  compound  fracture  of  both  bones  of  the  leg.  Note  the  position  of 
the  patella,  as  outlined  through  the  bandages,  and  the  relation  it  bears  to  the  foot  which 
is  everted  and  displaced  posteriorly.  Leg  below  the  fracture  is  flail-like  permitting  of 
displacement  in  any  direction.  Extensive  injuo'  to  soft  tissues.  The  tibia  and  fibula 
(upper  fragments)  penetrated  the  skin  through  the  wound  on  the  outer  side  of  the  leg 
as  indicated  by  "X"  in  plate.  The  blood  on  the  towel  is  coming  from  this  wound.  In- 
jury produced  by  heavy  wagon  loaded  with  three  tons  of  coal  passing  over  leg. 

be  placed.  When  both  bones  are  broken,  abnormal  mobility  is  much 
greater  than  when  the  tibia  alone  is  fractured.  It  is  not  uncom- 
mon to  see  the  end  of  either  the  upper  or  lower  tibial  fragment  pro- 
jecting through  the  skin  on  the  anterior  aspect  of  the  leg. 

Fracture  of  the  fibula  alone  is  not  attended  by  much  loss  of  func- 
tion unless  the  break  is  close  to  the  ankle,  and  even  then  the  author 
has  seen  cases  in  which  the  patient  was  able  to  walk,  in  spite  of 


tuo 


FRACTURES   AND    l)ISl,OC'AT10NS 


the  injury.  Pain  nccni's  witli  use  of  the  linih  and  pivstsure  ou  the 
shaft  of  the  hour  will  iirotlucc  ])ain  a1  tlir  site  of  the  lesion  even 
though  the  pressure  Ix-  ina(h'  above  oi-  liciow  the  level  of  fracture. 
Fracture  of  the  fil)nhi  neai'  the  ankle  may  disturb  the  mortice  of  the 
aid\le  joint  by  an  ontward  displacement  of  the  external  malleolus 
as  the  np|)er  end  of  till'  lowt'i'  IVaLzinent  is  displaced  toward  the 
tibia. 


(J9a. 


Figs.  692  and  693. — Two  views  of  an  oblique  fracture  of  tlie  tibia  a  few  inches 
above  the  ankle.  The  displacement  is  very  slight  between  the  tibial  fragments.  The  line 
of  the  fracture  can  be  recognized  only  by  careful  palpation.  This  almost  complete  absence 
of  deformity  is  due  to  the  fact  that  the  fibula  remains  intact  and  acts  as  a  splint  for  the 
broken  tibia.  Photograph  about  twelve  hours  following  the  accident.  Arrow  indicates 
position  of  fracture. 


Fracture  of  the  bones  of  the  leg  is  usually'  attended  by  severe 
traumatic  reaction  within  a  few  hours  of  the  accident.  Swelling  is 
pronounced  and  eechymosis  develops  in  the  region  of  the  fracture 
during  the  first  twenty-four  to  forty-eight  hours.  It  is  not  uncom- 
mon for  blebs  to  form  in  the  skin  at  any  time  during  the  first  week 
and  their  contents  may  be  either  blood  or  serum  or  a  mixture  of 
these  two  materials  (see  Fig.  689).  In  fractures  of  this  type  the 
injury  to  the  soft  tissues  may  be  so  great  that  the  fracture  itself  is 


FRACTURES    OF    SIlAP"rS    OK    THE    BONES   OF    LEG 


641 


only  of  secondary  importance.  If  the  fibula  remains  intact 
abnormal  mobility  will  usually  not  be  as  pronounced  as  when  both 
bones  are  broken.  Green-stick  fracture  of  the  tibia  sometirftes 
occurs  in  children  and  may  be  accompanied  by  such  slight  preter- 
natural mobility  as  to  render  recognition  difficult  (see  Fig.  690). 
Most  fractures  of  the  leg  are  accompanied  by  severe  traumatic  reac- 


Jm^     095. 

Fig-s.  694  and.  695. — Severe  compound,  comminuted  fracture  of  the  bones  of  the  le?. 
Hemorrhage  free.  Numerous  globules  of  fat  could  be  seen  in  the  blood  as  it  flowed  from 
the  wound  having  escaped  from  the  tissues  of  the  medullary  cavity.  These  globules  of 
fat  in  the  blood  remind  one  of  the  cases  of  fat  embolism  sometimes  encountered  in  frac- 
tures. The  lower  plate  (Fig.  695)  is  a  closer  view  of  the  same  case  after  the  blood 
has  been  sponged  away  so  the  fragments  of  the  tibia  may  be  seen. 


tion  but  occasionally  a  case  is  seen  in  which  the  causative  trauma 
has  been  just  sufficient  to  produce  the  fracture  and  the  resultant 
swelling  and  inflammation  are  slight.  In  fractures  produced  by 
great  trauma  the  skin  covering  the  tibia  may  be  extensively  torn 
and  loose  fragments  of  bone  may  be  seen  lying  in  the  wound.  In 
rare  instances  the  circulation  below  the  fracture  may  be  destroyed 
so  that  no  pulse  can  be  detected  in  .the  dorsalis  pedis,  the  foot  be- 


642 


FRACTl'RES    AND    DISLOCATIdNS 


eonu's  cold  jiiid   lit'i'lcss  and  is  latt'i'  roUowcd  by  iiaiigrciu'.     Symp- 
toms of  iit'fvt'  injury  arc  rare. 

Diag^nosis. — The  syinptoins  are,  as  a  rule,  pronouueed  and  there 
is  little  diiticiilty  in  recognizing  the  fracture.  The  deformity  is 
usually  so  characteristic  that  a  diagnosis  can  be  made  by  inspection 
aldiie.     Tile  details  of  the  fraetnrt'.  howcxci-.  are  often  impossible 


Pig.   696. 


697. 


Figs.  696  and  697. — Severe,  compound  fracture  of  the  tibia  and  fibula  in  their 
upper  thirds.  Upper  end  of  lower  tibial  fragment  is  displaced  upward  and  outward  and 
lies  just  under  cover  of  the  skin.  Extreme  laceration  and  damage  to  the  soft  tissues. 
It  is  this  type  of  fracture  wliich  usually  requires  amputation.  The  opening  in  the 
skin  is  the  result  of  trauma  at  the  time  of  the  accident.  Note  the  flail-like  attitude  of 
the  leg  below   the  fracture. 


to  determine  without  the  aid  of  the  X-ray.  Isolated  fracture  of 
the  fibula  maj^  go  unrecognized  unless  a  careful  examination  is 
made.  The  significant  fact,  when  the  fibular  shaft  alone  is  frac- 
tured, is  that  pressure  on  the  shaft  of  the  bone  produces  pain  at 
the  site  of  the  break  rather  than  at  the  point  of  pressure. 

Treatment. — The  emergency  treatment  of  fractures  of  the  leg  is 
of  considerable  importance.     Some  form  of  temporary  splint  should 


FRACTURES    OP    SHAPT8   OP    THE    BONER   OF   LEG 


643 


be  employed  in  transporting  the  patient  from  the  scene  of  the 
accident  to  the  hospital  or  home.  The  greatest  care  should  be  exer- 
cised to  avoid  converting  a  simj)le  fracture  into  a  compound  one. 


-^ 


-^ 


-^ir 


2 


Fig.    698. — Folding   fracture-box    laid    open. 


Fig.   699. — Same  closed. 


This  may  be  easily  done  as  the  patient  is  being  moved,  or  during 
careless  manipulation  of  the  leg.  The  less  the  parts  are  disturbed 
at  this  time  the  less  pronounced  will  be  the  trauniatic  reaction,  dur- 
ing the  following  week. 


^. 

B 



A 

Fig.  '700. —  (A)  Padding  in  fracture-box  to  conform  to  the  posterior  aspect  of  the 
leg.  (B)  Fracture-box  closed  and  sides  held  in  position  with  three  strips  of  adhesive 
plaster. 

In  the  reduction  of  fractures  of  the  leg  an  anesthetic  should  be 
employed  to  relieve  the  pain  and  overcome  muscular  spasm.  If 
the  foot  is  grasped  above  the  ankle  and  strong  traction  exerted 


644 


FRACTURES   AND    DTST.OCATIONS 


while  an  assistant  makes  counter-traction  just  l)elo\v  the  knee,  it 
will  usually  be  possible  to  return  the  fi-aguients  to  their  proper 
relations  without  great  difficulty.  Coaptation  pressure  on  the  frag- 
ments may  be  necessary  and  in  transverse  fractures  angulation  of 
the  leg  at  the  seat  of  the  break  may  be  required  before  an  engage- 
ment of  the  fractured  surfaces  can  be  had.  Pressure  should  not  be 
made  directly  over  the  prominent  end  of  a  fragment  lest  the  condi- 
tion be  rendered  compound  by  penetration  of  the  skin  from  within. 
It  is  common  in  spiral  and  oblique  fractures  to  see  recurrence  of 


Figs.    7Ul    and    702. — l^cs;   is   stcii    in    \'v: 
side    of    box    let    down    for    inspection    :in<l 
fracture-box  closed  and  fastened. 


.iMl.inMi 


ith    pnipir   ijadclinn    in    |.iluce    and 
1     iii     ilre^sinns,     and    again    with 


deformity  take  place  as  soon  as  the  foot  is  released,  and  it  is  this 
type  of  break  which  most  needs  operative  treatment  and  internal 
fixation. 

The  treatment  of  fractures  of  the  leg  varies  according  to  the 
amount  of  trauma  and  laceration  sustained  hy  the  soft  tissues  and 
the  facility  with  which  the  fragments  can  be  held  in  reduction. 
During  the  first  week  or  ten  days  the  leg  should  be  iimnobilized  in 
some  form  of  temporary  splint  which  will  steady  the  parts  and  3^et 
allow  perfect!}^  for  frequent  inspection  and  adjustments,  during 
the  onset  and  subsidence  of  swelling.     A   number  of  appliances, 


FRACTURES   OF    SHAFTS   OP   THE   BONES   OF   LEG 


645 


varying  in  detail,  tliough  the  same  in  principle,  have  been  employed 
during  this  period  for  the  teni[)Grary  treatment  of  fractures  of  the 
leg.     The    fractnre-hox,    pillow    splint,    posterior    gu+ter   splint    of 


Fig.  703. — Adhesive  plaster  applied  for  traction  and  coun- 
ter-traction, with  the  short  Desaiilt  splint.  Adhesive  on  upper 
part  of  leg-  is  applied  to  pull  upward  while  that  on  the  lower 
part  of   leg   to   pull  downward  when   the   splint   is   in   position. 

Fig.  704. — Short  Desault  splint  in  position,  with  padding 
about  leg.  Tightening  the  screw  at  the  foot  of  the  splint  affords 
traction   and  counter-traction. 

plaster,  Du  Puy  splint,  etc.,  have  all  been  suc- 
cessfully used,  and  it  is  largely  a  matter  of 
preference  with  the  surgeon  which  of  these  meth- 
ods of  fixation  is  employed.  The  author  has 
used  both  the  pillow  splint  and  the  fracture-box 
with  considerable  satisfaction.  The  fracture- 
box  is  made  of  four  pieces  of  wood  as  shown  in 
Figs.  698  and  699.'  The  inside  of  the  box  is 
well  padded  with  cotton  batting  to  fill  in  the 
spaces  between  the  leg  and  the  walls  of  the  box. 
The  sides  of  the  box  should  be  hinged  so  they  can 
be  lowered  for  inspection  of  the  limb  and  read- 
justment of  the  padding.  The  pillow  splint  is 
made  by  placing  the  leg  longitudinally  on  a  pil- 
low, which  is  then  folded  up  on  either  side  of 
the  leg  and  held  in  position  by  encircling  straps 
of  adhesive,  bandages,  or  ordinary  straps  with 
buckles,  either  of  canvas  or  leather.  If  three 
splints  are  placed  in  position  before  the  straps 
are  tightened  the  whole  appliance  will  be  ren- 
dered much  more  rigid.  These  splints  should  be  of  light  wood 
three  and  a  half  to  four  inches  in  width  and  should  be  placed 
between    the    straps    and    the    pillow,    one    on    either    side    and 


704. 


646 


FRACTURES    AND    DISLOCATIONS 


Fig  705. — Cabot  posterior  wire  splint.  A.  shows  wire  bent  to  fonform  to  shape 
of  leg  B  shows  same  padded  aud  bandaged.  C.  shows  same  after  space  has  been 
filled  in  bv  bandaging.     D.  shows  splint  applied  to  leg  and  bandaged  in  position. 


Fig     706. — N.    B.    Smith's   suspension   splint.      A.   shows   wire   splint   bent    to   conform 
to  anterior  surface  of  leg  B.     C.  shows  splint  applied  and  leg  suspended. 


FRACTURES    OP    SHAFTS   OF   THE    BONES   OF   LEG 


647 


the  third  posteriorly.  The  pillow  splint  and  fraeture-box  are  as 
good  as  any  and  can  be  improvised  even  under  unfavorable 
surrounding's.  The  Cabot  posterior  wire  splint  and  side  splints 
are    a    favorite    method    with    some    surgeons.     The     fragments 


Fig.    707. 


Fig.    708. 


Fig.  707. — Elevated  fracture-box.  Of  advantage  in  cases  in  whicli  circulation  of  leg 
is  much  injured  or  in  which  flexion  is  required  to  maintain  reduction.  It  is  difficult, 
however,  to  render  this  form  of  box  stable  in  bed. 

Fig.   708. — Cradle  used  to  prevent  bed  clothes  from  resting  on  injured  member. 


should  be  brought  into  alignment  with  the  least  possible  manip- 
ulation as  the  leg  is  being  placed  on  the  temporary  splint. 
Oblique  and  spiral  fractures  are  common  in  the  shaft  of  the  tibia 
and  it  may  be  necessary  to  control  the  overriding  deformity  during 


Fig.    709. 

Figs.    709    and    710. — Methods   of    securing    traction    on   fractures    near   the    ankle   by 
means  of  adhesive  straps. 


Fig.    711.  Fig.    712. 

Fig.    711. — Old    shoe   with   toe   cut   out   and    adhesive   straps   for   obtaining   extension. 
Fig.    712. — Method   of  relieving  the  heel   from  pressure. 

this  time,  especially  if  the  pointed  end  of  one  of  the  fragments 
threatens  to  perforate  the  skin,  as  is  not  infrequently  the  case. 
Under  these  circumstances  an  extension  apparatus  should  be  ap- 
plied to  the  foot.     This  is  often  a  difficult  matter  if  the  materials 


648 


FRACTURES   AND   DISLOCATIONS 


used  arc  tlic  siiiiit'  as  those  nnploN cd  in  l>iick"s  t'xiciision,  in  frae- 
tures  ol"  tilt'  hip.  Adlifsixc  j)histci'  when  applied  lo  Ihe  foot  and 
aiikli'  is  liki'ly  to  irritate  the  skin,  l)ecause  of  the  small  area  to 
wliicli  it  eaii  be  attached.  The  antlior  has  round  the  following 
method  very  satist'actoi-y  in  instances  in  whicli  extension  was  found 
necessary.     Tlie  patient's  slioc  is  cut  so  that  the  "'upper"  is  divided 


Pig.   714. 


Fig.  713. — .interior  and  ixisterior  jjla-ster  splints  apiilied  to  leg  and  held  in  posi- 
tion   by    encircling   straps   of    adhe.sive    plaster. 

Pig.  714. — Plaster  stirrup.  The  two  side  splints  are  made  of  one  continuous  piece 
of  gauze  which  passes  under  foot.  As  a  permanent  dressing  this  sjilint  is  probably  the 
most  efficient  and  satisfactory  in  fractures  of  the  leg. 


from  the  sole.  Slits  are  then  cut  in  the  sides  of  the  "upper"  and 
adhesive  straps  passed  through  them  to  he  carried  below  the  foot 
to  a  spreader,  the  same  as  employed  in  Buck's  extension.  The 
upper  is  then  placed  on  the  foot,  the  lacings  tightened  and  a  weight 
attached  to  the  cord  after  it  has  been  passed  through  a  pulley  se- 
cured to  the  foot  of  the  bed.     Six,  eight  or  ten  pounds  will  usually 


FRACTURES   OF    SHAFTS   OF   THE   BONES   OF   LEG  649 

suffice  in  correcting  the  deformity  hut  the  amount  of  weight  em- 
ployed should  he  governed  entirely  hy  the  degree  of  nmscular 
spasm  to  be  overcome.  Extension  can  be  exerted  in  this  way 
without  irritating  the  foot  and  ankle  during  the  time  it  is  fixed  on 
the  temporary  splint;  counter-extension  is  had  by  raising  the  lower 
extremity  on  an  incline  plane  or  by  raising  the  foot  of  the  bed. 
Instead  of  splints,  sand  l)ags  may  be  placed  on  either  side  of  the 
leg  and  will  serve  the  purpose  well  in  steadying  the  parts. 

It  is  often  impossible  to  forecast  the  degree  of  traumatic  reaction 
which  will  follow  in  a  given  case  and  it  is  therefore  best  to  post- 
pone the  application  of  a  permanent  splint  until  this  reaction  has 
passed.  The  tension  produced  by  the  swelling,  the  internal  lacer- 
ation of  soft  tissues  by  the  fragments  at  the  time  of  injury,  and 
the  not  infrequent  venous  thrombosis  about  the  site  of  the  fracture 
are  conditions  tending  to  impede  circulation  and  demand  dressings 
which  do  not  constrict  the  leg.  The  plaster  cast  has  been  exten- 
sively used  in  the  early  treatment  of  fractures  of  the  leg  and  good 
results  have  attended  its  use,  yet  the  author  feels  that  it  is  an 
unsafe  appliance  and  is  inferior  in  every  way  to  the  plaster  stirrup 
or  plaster  splints.  With  either  plaster  splints  or  the  plaster  stirrup 
the  dressings  may  be  tightened  or  loosened  as  the  occasion  demands 
and  during  the  entire  course  of  the  case  a  strip  of  skin,  extending 
the  length  of  the  leg,  is  open  to  inspection.  The  plaster  cast  is 
much  safer  during  the  later  half  of  the  after-treatment  and  forms 
a  good  method  of  fixation  for  ambulatory  treatment. 

Isolated  fractures  of  the  tibia  are  rarely  followed  by  much  swell- 
ing, and  fracture  of  the  tibia  alone  is  usually  productive  of  a  much 
milder  traumatic  reaction  than  occurs  when  both  bones  of  the  leg 
are  fractured.  The  surgeon  is  usually  able  to  estimate,  with  more 
or  less  accuracy,  the  degree  of  traumatic  reaction  to  follow  in  a 
given  case.  Occasionally,  however,  cases  are  encountered  which 
promise  little  in  the  way  of  swelling  when  first  seen,  and  yet  a  few 
days  later  show  the  most  marked  symptoms.  If  such  a  case  is 
wearing  a  permanent  dressing  of  the  nature  of  a  plaster  cast,  great 
damage  may  be  done  to  the  leg  before  either  the  surgeon  or  the 
patient  realizes  the  condition. 

Numerous  modifications  of  splints  (such  as  the  Desault  and  plas- 
ter traction  splints)  have  been  devised  to  maintain  reduction  by 
means  of  extension  and  counter-extension  until  the  fragments  have 
become  firmly  enough  united  to  prevent  displacement.     These  ap- 


650  FRACTURES   AND   DISLOCATIONS 

})liaiioes  are  well  enough  as  a  ]>enuanent  dressing,  in  instances  in 
which  operation  is  contraiiulicated  hecause  ot"  disease,  ag(>  or  lack 
of  surgical  I'arilities,  liul  under  ordinary  cii-cniiistanees  tliey  are 
to  he  considered  as  ohsoh'te  and  to  be  disearded  in  favoi-  ol'  operative 
methods  with  direct  tixation  of  the  fi-agnients. 

The  treatment  of  compound  fractiii-es  of  the  l)ones  of  tlie  leg  is 
essentially  oi)erative,  at  tlie  present  time,  and  witli  tlie  vastly  better 
results  obtained  in  this  way,  there  can  be  nothing  but  censure  for 
non-operative  metliods,  [jrovided  there  are  no  constitutional  con- 
traindications and  surgical  facilities  are  available.  (See  "Opera- 
tive Treatment,"  below.)  A  conunon  and  serious  mistake  in  tlie 
treatment  of  compound  fractures  in  this  region  is  to  ett'ect  an  inune- 
diate  reduction  as  soon  as  the  case  is  seen,  often  on  the  street  or  in 
the  factory.  This  i)i'ocedure  has  probably  been  resi)onsible  for  the 
loss  of  numy  legs  which  could  otherwise  have  been  saved.  The  ends 
of  the  fragnuMits  projecting  through  the  skin  nuist  be  considered  in- 
fected and  if  an  iunnediate  reduction  is  performed  the  patient  will 
be  fortunate,  to  say  the  least,  if  the  entire  tract  does  not  become 
septic,  with  the  usual  disastrous  train  of  symptoms  following. 
Instead  of  attempting  immediate  reduction,  the  wound  and  exposed 
bone  should  be  covered  with  a  sterile  dressing  and  the  patient  re- 
moved to  surroundings  in  which  proper  surgical  procedures  can  be 
carried  out.  (See  "Treatment  of  Compound  Fractures,"  page 
789.) 

Operative  Treatment. — There  are  four  sets  of  circumstances 
which  commonly  call  for  operative  treatment.  First,  to  accom- 
plish and  maintain  reduction  in  recent  cases  in  which  non-operative 
methods  have  failed ;  second,  in  the  treatment  of  compound  frac- 
tures; third,  when  non-union  is  present,  and  fourth,  for  the  correc- 
tion of  old  fracture  deformities. 

A  large  proportion  of  closed  fractures  of  the  leg  demand  operative 
intervention  to  secure  the  best  results.  The  best  time  for  operation 
in  simple  cases  is  after  the  traumatic  reaction  has  subsided,  which 
will  be  at  the  end  of  a  week  or  ten  days.  The  most  aseptic  tech- 
nique should  be  followed  and  other  precautions  observed  such  as 
are  mentioned  on  i)age  754  under  the  heading  of  "Open 
Treatment  of  Fractures."  A  longitudinal  incision  should  be 
made,  preferably  to  the  outer  side  of  the  midplane  of  the  leg,  so 
that  the  external  surface  of  the  bone  will  be  exposed.  It  is  not 
advisable  to  make  the  incision  opposite  the  internal  surface  of  the 


FRACTURES    OP    SHAFTS    OF    THE    BONES   OF    LEG 


651 


tibia,  since  this  face  of  the  shaft  is  subcutaneous.  In  difficult  cases 
two  incisions  may  be  made,  one  as  already  described  and  the  other 
opposite  the  internal  border  of  the  bone  on  the  inner  aspect  of  the 
leg.  Traction  and  direct  manipulation  of  the  fragments  will  ac- 
complish reduction  and  occasionally  it  may  be  possible  to  obtain  a 
solid  engagement  of  the  serrated  surfaces,  thus  obviating  the  ne- 
cessity of  direct  fixation.  In  most  instances,  however,  in  which 
operation  is  indicated,  it  will  be  found  necessary  to  resort  to  some 
form  of  internal  fixation  to  prevent  recurrence  of  deformity.  A 
very  satisfactory  method  of  securing  the  fragments,  and  one  which 


Fig.   715. 


Fig.    716. 


Figs.    715    aud   716. — Lateral   and   anteroposterior   views    of   comminuted   fracture   of 
tibia.      Transverse  fracture  of   fibula. 


will  serve  the  purpose  in  most  oblique  and  spiral  fractures,  is  shown 
in  Fig.  717.  This  consists  in  passing  two  wires  about  the  shaft  of 
the  bone.  The  distance  between  them  should  be  at  least  an  inch, 
to  secure  the  proper  leverage.  In  some  instances  the  Lane  plate 
can  be  used  to  advantage.  Transverse  fractures  can  often  be  en- 
gaged in  such  a  manner  that  no  internal  fixation  is  necessary.  If 
a  plate  is  used  it  is  preferable  to  place  it  on  the  external  surface 
of  the  shaft  so  that  it  will  not  be  subcutaneous.  In  knotting  or 
twisting  wire,  the  twists  or  knots  should  be  placed  on  this  same 
surface.  With  the  wires  or  plate  in  position  the  strength  of  the 
fixation  should  be  gently  tested  to  see  that  the  fragments  are 
solidly  enough  held.     It  should  be  possible  to  raise  the  foot  by  the 


652 


FRACTURES   AND   DISLOCATIONS 


heel  witliout  disturbing  tlic  i-rlative  positions  of  the  fragments. 
AVlu-n  the  internal  fixation  has  been  eonipleted  and  tested  the 
wound  sliould  ])e  closed  and  a  small  drain  of  silkwoi'm  ^rut  placed 


Fig.    717. 


Fig.    718. 


!■  ig.  717. — Same  case  as  slinwn  in  Figs.  71.'^  and  71(1.  X-ray  plate  made  three 
weeks  after  operation  in  w'nicli  tlie  Ijoncs  were  wiri'd  in  two  iilnces.  Aseptic  healing 
and   ultimately   perfect   function. 

Fig.  718. — Same  leg  shown  on  posterior  plaster  splint.  The  anterior  splint  lias  been 
removed  to  di-ess  wounds.      (See  Fig.   7i:!.) 

in  position  to  allow  Ibc  cscajx'  of  blood  and  scniiii  during  the  first 
twenty-four  or  forty-eight  houi's.  A  heavy  plaster  stirrup  sliould 
be  applied  before  the  patient  comes  out  of  the  anesthetic.  A  quick 
drying  plaster  sliould  be  used  so  that  the  stirrup  may  be  well  set 


FRACTURES    OF    SHAFTS    OF    THE    HONES    Ol"^    \jK(i  65.'^ 

before  the  patient  leaves  the  operating  room.  If  a  sheet,  rinrrovvly 
folded  lengthwise,  is  passed  once  around  the  thigh  just  above  the 
knee,  and  the  ends  secured  to  the  side  rails  of  the  bed,  it  will  pre- 
vent the  patient  moving  the  lower  extremity  while  coming  out  of 
the  anesthetic,  and  will  be  of  valuable  assistance  to  the  attendant 
during  this  time.  The  leg  should  not  be  covered  with  the  bed 
clothes  during  the  first  twenty-four  hours  following  operation,  so 
that  the  plaster  may  become  thoroughly  hardened  and  dried  out. 
Failure  to  observe  this  precaution  will  probably  necessitate  the 
reapplica^ion  of  the  dressing,  to  say  nothing  of  the  possibility  of 
damage  to  the  limb  through  lack  of  support. 

In  compound  cases  the  patient  should  be  taken  to  the  operating 
room  as  soon  following  the  accident  as  possible.  An  anesthetic 
should  be  given,  the  skin  surrounding  the  wound  painted  with 
five  percent  iodine  and  the  incision  enlarged  if  necessary.  The 
wound  should  be  irrigated  with  a  few  gallons  of  sterile  salt  solu- 
tion. Completely  detached  fragments  of  bone  should  be  removed 
and  the  main  fragments  brought  into  as  good  alignment  as  possible. 
Devitalized  tissue  should  be  trimmed  away  and  oozing  controlled 
by  hot  salt  solution.  Active  bleeding  from  small  arteries  should  be 
stopped  by  torsion,  if  possible,  rather  than  by  ligature.  Internal 
fixation  of  the  fragments  at  this  time  is  contraindicated  regardless 
of  the  material  used.  The  freshened  surfaces  of  the  wound  should 
be  approximated  and  a  small  drain  of  silkworm  gut  left  in  position 
to  allow  the  escape  of  blood  and  serum.  Dressings  are  then  ap- 
plied to  the  wound,  the  leg  covered  with  a  layer  of  sheet  cotton 
and  a  plaster  stirrup  employed  as  already  described.  "When  the 
patient  is  transferred  to  the  bed  the  leg  should  be  w^ell  elevated 
and  an  ice  cap  (one  that  does  not  leak)  is  placed  on  the  anterior 
aspect  of  the  leg  in  the  region  of  the  fracture.  An  attempt  should 
be  made  during  the  operation  to  secure  as  accurate  reduction  as 
possible,  yet  it  should  be  remembered,  in  these  cases,  that  accurate 
reduction  at  this  time  is  not  the  essential.  The  most  important 
factor  is  to  obtain  healing  of  the  wound  which  renders  the  frac- 
ture compound.  If  the  position  of  the  fragments  is  bad,  a  second 
operation  may  be  done  at  some  later  date,  after  the  wound  has 
healed  and  the  surgeon  is  free  to  work  in  an  aseptic  field.  This 
can  usually  be  done  at  the  end  of  ten  days  or  two  weeks.  If  sup- 
puration and  infection  follow,  in  spite  of  the  measures  just  ad- 
vised, the  fracture  must  be  treated  along  general  surgical  lines 


654  FRACTURES    AND    DISLOCATIONS 

Avith  free  drainage,  etc.  The  nuniber  of  infected  cases,  however, 
followincr  this  line  of  procedure  will  be  sur])risingly  small  as  com- 
pared with  the  cases  in  which  local  aiiplications  of  hichloi-id  of 
mei'cury  and  other  useless  antiscplics  are  the  agents  dcpciidcd  niton 
to  prevent  infection. 

Operation  may  be  indicated  to  coricct  old  Iratdnrc  dcfofnuties 
in  whieli  the  pooi-  alignment  of  fi'agmeids  is  accomj)anit'd  by  pro- 
nounced disturi)ance  in  function.  In  a  case  of  this  type  the  sur- 
geon should  not  be  overanxious  to  operate  if  the  patient  is  showing 
any  improvement  whatever.  The  restoration  of  function  ma\-  be 
greatly  delayed  and  still  the  patient  nuiy  ultimately  obtain  a  serv- 
iceable member  without  surgical  intervention.  When  oi)eration  is 
necessary  the  procedure  is  similar  to  that  already  described,  with 
the  addition  of  appropriate  osteotomy  to  bring  the  fragments  back 
into  proper  position. 

When  operation  is  called  for  because  of  non-union  the  tirst  indica- 
tion is  to  seek  the  cause  of  the  failure  in  union.    (See  Chapter  LXI.) 

After-Treatment. — A  great  deal  of  care  and  attention  is  called  for 
in  the  after-treatment  to  keep  the  patient  comfortable  and  to  see 
that  the  dressings  are  performing  their  proper  function.  Eepeated 
adjustments  will  be  necessary,  especially  during  the  time  the  leg 
is  changing  in  size,  with  the  onset  and  passing  oft"  of  swelling. 
During  the  first  week  or  ten  days  the  leg  should  be  inspected  at 
least  dail}'  and  readjustments  made.  Blebs  should  be  opened  after 
they  have  fully  formed  and  the  denuded  surfaces  dusted  with 
boric  acid  or  some  other  efficient  dusting  powder.  These  surfaces 
should  receive  the  most  careful  attention  and  it  nuist  not  be  for- 
gotten that  the  member  may  become  infected  through  such  an 
atrium,  especially  in  the  presence  of  low  resistance  in  the  surround- 
ing tissues. 

The  sooner  ambulatory  treatment  is  instituted,  following  the 
subsidence  of  traumatic  reaction,  the  better  for  the  patient  in  gen- 
eral and  the  fracture  in  particular.  In  non-operative  cases  the 
patient  may  be  gotten  up  on  crutches  within  five  or  six  days  of  the 
application  of  a  permanent  splint.  When  open  treatment  has  been 
employed  to  accomplish  reduction,  a  week  should  elapse  following 
the  operation,  before  the  patient  is  allowed  up.  In  compound 
cases  the  wound  should  be  well  healed  and  the  fragments  in  good 
position  for  a  week  or  more  before  ambulatory  treatment  is  insti- 
tuted.    Complicated  cases  should  remain  in  bed  until  the  outlook 


FRACTUKIOS    OK    SHAFTS    OF    'I'llE    I'.ONKS    OK    IjKG 


655 


is  favorable  and  convalescence  well  established.  The  patient  sliouhl 
be  allowed  up  for  only  a  few  minutes  during  the  first  day.  The 
time  should  be  increased  the  second  day,  and  so  on  during  the  fol- 
lowing week  until  the  limb  can  be  held  in  the  dependent  position 
without  undue  swelling  and  pain.  During  this  time  he  will  gain 
control  of  the  crutches,  and  the  annoying  sensations  in  the  leg, 
attendant  upon  the  erect  position,  will  gradually  grow  less  and 
finally  disappear.  At  the  end  of  nine  or  ten  weeks  the  foot  may 
be  placed  on  the  floor  as  the  patient  walks  with  crutches.  During 
the  following  three  or  four  weeks  weight  bearing  should  be  grad- 
ually resumed.     During  this  time  the  surgeon  should  wateh  the  leg 


Fig.    719. — Ambulatory   pneumatic   splint   as   used   iu   fractures   of   the   leg 
extension  mechanism   at  the   end   of   the   splint. 


Note  the 


carefully  for  signs  of  a  weak  callus.  The  slightest  bowing  or  short- 
ening of  the  leg  demands  immediate  cessation  of  weight  bearing. 
Swelling  is  often  persistent  and  pronounced  and  should  be  treated 
by  daily  massage  and  immersion  of  the  leg  in  hot  Avater  once  or 
twice  a  day.  An  elastic  stocking  Avorn  during  the  day  will  aid 
materially  in  controlling  this  swelling.  The  older  the  patient  the 
longer  the  time  necessary  for  the  formation  of  firm  weight  bearing 
callus.  In  the  very  aged  it  may  be  impossible  to  obtain  union  at 
any  time.  In  the  exceptional  case  in  which  the  surgeon  maj^  be 
in  doubt  as  to  the  best  time  for  the  resumption  of  function,  an 
X-ray  plate  will  afford  the  desired  information  concerning  the  con- 
dition and  progress  of  callus  formation. 


656 


FRACTIRES    AND    niSI,(M'ATl(1N:^ 


Fig.  720. — Old  fi'a;-ture  of  the  tibiu  and  fibula  with  discluirgin?  .sinus  eight  years 
later.  The  condition  has  been  an  intermittent  source  of  trouble  during  the  entire  eight 
years.  This  is  a  good  example  of  a  type  of  ease  requiring  operation  for  the  removal 
of   necrotic   bone. 


Fig.  721. — Picture  taken  to  sliow  the  swelling  which  so  fretiuentlv  persists  follow- 
ing fractures  of  the  l)ones  of  the  leg  especially  with  patients  past  middle  life.  Picture 
taken  some  months  following  the  accident.  The  ring  about  the  leg  corresponds  to  the 
upper  end  of  the  elastic  stocking. 


f^RACTTIRES    OF    SHAP^TS    OF    THE    BONES    OF    IjEC, 


657 


Prognosis. — The  prognosis  in  fractures  of  the  l(;g  is  extremely 
variable  and  depends  largely  on  the  associated  injuries  to  the  soft 
tissues  and  whether  or  not  a  compound  fracture  becomes  infected. 
Persistent  swelling  is  common  and  may  last  for  years.  It  is  de- 
pendent on  the  damage  done  to  the  circulation  at  the  time  of  the 
injury  and  on  the  development  of  venous  thrombosis  following  the 
accident.  The  more  severe  these  conditions,  the  more  pronounced 
and  persistent  will  be  the  swelling  when  function  is  resumccl.  Pain 
in  the  leg  may  persist  for  months  or  even  years  following  the  acci- 
dent. Considerable  disturbance  in  function  usually  follows  vicious 
union  of  the  fragments  and  is  due  to  the  mechanical  strain  imposed 


Fig.    722. 


Fig.    723. 


Fig.    72.5. 


Figs.  722,   723,  724  and  72.5. — Show  tlie  mechanical  disturbances  which  follow  union 

with    deformity.      When    the  leg    diverges    from    the    weight-bearing    line    the    leg    will    be 

mechanically   "off"    and   as   a  result   there   will   be   more   or   less   permanent    disturbance   in 
function. 


on  both  muscle  and  bone  by  this  faulty  position.  The  more  per- 
fect the  apposition  of  the  fragments  and  the  less  the  damage  to  soft 
tissues  at  the  time  of  the  accident,  the  less  pronounced  will  these 
annoying  sequelae  be.  The  percentage  of  cases  in  which  perfect 
and  prompt  restoration  of  function  occurs,  has  greatly  increased 
since  the  advent  of  open  treatment  for  the  accurate  correction  of 
deformity. 

In  compound  infected  eases,  sinuses  may  persist  until  the 
necrotic  bone  from  which  they  lead  is  removed  by  operation. 
Kefracture  of  the  bones  of  the  leg  may  occur  if  sufficient  strain  is 
sustained  before  the  callus  becomes  thoroughly  hardened.  Kefrac- 
ture is  through  the  callus  and  not  the  fragments.     About  one-half 


658  FKACTl'RES    AND    DISLOCATIONS 

to  two-thirds  the  time  required  for  union  in  th(>  ori^nnal  break  is 
necessary  for  union  in  a  fraetured  rallus.  Hnil)olisiii  from  a  de- 
tached portion  of  thrond)us  or  a  fat  cniholus  may  ])i'odu{'e  immedi- 
ate deatli.  Infection  in  compound  cases  may  result  in  the  loss  of 
the  leg,  or  if  severe,  even  death.  Desti-uetion  of  tlte  eii-cidation  in 
severe  crushing  injuries  calls  for  iiiiiniMJi.-ite  jimpulation. 


CHAPTER  XL VI. 

POTT'S  FRACTURE. 

Pott's  fracture  is  both  a  fracture  and  a  dislocation,  and  although 
it  is  usually  included  under  the  heading  of  fractures,  yet  it  is 
probably  more  in  accordance  with  the  pathology  of  the  condition 
to  consider  it  as  a  dislocation  complicated  by  fracture. 

Aside  from  fracture  of  the  fibula.  Pott's  fracture  is  the  most 
common  injury  of  importance  occurring  in  this  region,  and  be- 
cause of  this  frequency  and  the  poor  results  so  often  seen  following 
its  improper  treatment,  it  will  be  taken  up  under  a  special  heading. 

Surgical  Anatomy. — There  are  three  bones  entering  into  the 
formation  of  the  ankle  joint ;  the  tibia,  fibula  and  astragalus,  and 
the  disposition  of  these  three  bones  is  of  great  importance  surgically. 
The  trochlear  surface  of  the  astragalus  fits  the  articular  surface 
of  the  lower  end  of  the  tibia  and  is  held  in  place  laterally  b}-  the 
malleoli.  Lateral  motion  between  the  astragalus  and  tibia  is  pre- 
vented by  the  tight,  firm,  mortise-like  formation  of  the  tibia  and 
fibula.  The  two  latter  bones  are  held  together  by  the  lower  tibio- 
fibular ligaments,  the  most  important  of  which  is  the  inferior  in- 
terosseus,  which  passes  between  the  contiguous  rough  surfaces  of 
the  tibia  and  fibula.  These  ligaments  are  so  strong  that  separation 
of  the  two  bones  rarely  takes  place  without  fracture  of  either  the 
tibia  or  fibula.  The  lateral  ligaments  are  also  of  great  strength 
and  are  more  likely  to  tear  away  their  attachments  than  to  suffer 
rupture.  They  bind  the  astragalus  and  calcaneum  to  the  lower 
end  of  the  tibia  but  have  little  to  do  with  the  limitation  of  normal 
flexion  and  extension.  The  anterior  and  posterior  ligaments  are 
thin,  loose  and  lax,  and  are  not  brought  to  a  tension  until  the  ankle 
either  comes  to  extreme  flexion  or  extension.  When  the  foot  is 
depressed  to  its  limit  of  motion  the  anterior  ligament  becomes  taut 
and  in  like  manner  the  posterior  ligament  is  brought  to  a  tension 
when  the  ankle  is  dorsally  flexed.  Distention  of  the  joint  is  first 
noted  in  the  bend  of  the  ankle  w^here  the  thin  anterior  ligament  is 
pushed  forward   by  the   fluids   within  the   articular   cavity.     The 

659 


660 


FRACTURES   AND   DISLOCATIONS 


outer  malleolus  is  longer  and  extends  to  a  lower  level  than  the 
inner  nuiUe'olus.  11'  the  nornuil  alignment  of  the  hones  of  the  leg 
with  tiie  astragalus  and  calcaneum  is  observed  it  will  be  noted  that 
tlie  heel  rests  on  the  ground  outside  of  tiie  median  i)lane  of  the 
leg  (see  Figs.  726  and  727).  It  will  he  readily  seen,  therefore, 
that  violenee  ap|)li('d  in  a  longitudinal  dirt'i-tion,  such  as  is  sus- 
tained in  a  fall  from  a  height  in  winch  tlie  patient  lands  squarely 
on  tiie  foot,  will  tend  to  displace  the  foot  outward  as  well  as  up- 


Fi;;.  72G. — Shows  the  movtise  foj'med  by  the  tibia  and  fibula  into  which  the  astragalus 
fits.  E.M.,  External  Malleolus;  I.M.,  Internal  Malleolus;  A.,  Astragalus;  E.A.,  Head 
of   Astragalus. 

Fig.  727. — Same  view  of  ankle  with  calcaneum  in  position.  A  line  drawn  through 
the  long  axis  of  the  tibia  falls  to  the  inner  side  of  the  heel,  hence  the  frequency  of  talipes 
valgus  in  injuries  of  this  region.  E.M.,  External  malleolus;  I.M.,  Internal  malleolus; 
A.,  Astragalus;  H.A.,  Head  of  Astragalus;   C,  Calcaneum. 


wai'd.  It  is  ai)parent  that  this  disi)laeement  cannot  take  place 
without  producing  fracture  and  ligamentous  rupture.  The  points 
of  least  resistance  M'ill  be  found  in  the  fibula  just  above  the  lower 
tibio-fibular  articulation  and  in  the  internal  lateral  ligament  of  the 
ankle  joint  or  its  attachment  to  the  inner  malleolus.  When  these 
conditions  prevail  we  have  the  typical  Pott's  fracture  as  shown  in 
Figs.  729  to  731.  Compare  the  positions  of  the  bones  as  indicated 
in  Fig.  729  with  the  clinical  appearance  of  the  deformity  as  shown 


POTT  S  FRACTURE 


661 


in  Figs.  740  to  745.  Outward  rotatifjn  of  tlic  loot,  on  u  juore  or 
less  vertical  axis  passing  through  the  astragalus,  i)robably  plays  a 
part  in  the  production  of  many  Pott's  fractures,  by  prying  the 
malleoli  apart.  When  this  type  of  strain  enters  into  the  causative 
trauma  the  fibular  fracture  is  usually  spiral  instead  of  transverse. 
In  addition  to  the  lesions  just  mentioned  we  may  find  either  the 


Fig.    728. — Normal  ankle  showing  the  epiphyses  at  thirteen  years  of  age. 

anterior  or  posterior  margins  of  the  lower  tibial  surface  broken  off 
and  displaced. 

The  constant  element  in  Pott's  fracture  consists  of  a-  fracture 
of  the  fibula  within  two  or  three  inches  of  the  lower  tibio-fibular 
articulation.  The  variable  element  is  at  the  inner  malleolus,  where 
either  the  deltoid  ligament  is  ruptured  or  the  tip  of  the  inner 
malleolus  torn  away.  Numerous  descriptions  have  been  given  of 
the  exact  manner  in  which  a  Pott's  fracture  is  produced  and  the 
order  in  which  the  different  lesions  take  place ;  as  a  matter  of  fact 


662 


FRACTURES   AND   DISLOCATIONS 


.&1EL 


Fig.   729. 


Fig.    730. 


Fig.  729. — Pott's  fracture  with  tlie  usual  (iu(\\:(itl  disijliiccincnt.  Note  the  space 
between  tlie  inner  malleohis  and  tlio  astrasahis. 

Fi^.  730. — Variant  of  Pott'.s  fracture.  Tncoiiiplrd'  fracture  of  iiliuhi  witli  avulsion 
of   portion   of   til)ia,    corresi)on(liiiK   to   insertion    of   lower   titiio-til)ular    liuauuMit. 


Fig.    733. 


Fig.    731. — Pott's   fracture.      Comminution   of   fibula    ami    fracture   of   inner   malleolus. 

Fig.    732. — Pott's   fracture.      Comminution   of  fibula   and  fracture  of   inner   malleolus. 

Fig.  733. — Variant  of  Pott's  fracture.  Fracture  of  inner  malleolus  and  diastasis  of 
lower  tibio-fibular  joint.  The  separation  previously  existing  between  the  lower  ends  of 
the  tibia  and  fibula  has  been  corrected  at  the  time  of  reduction,  and  hence  the  diastasis 
is  not  apparent  in  the  Rontgenogram. 


POTT  S  FRACTURE 


66;i 


it  is  difficult  to  state  whether  the  internal  lateral  ligament  ruptures 
before;  the  fibula  breaks,  or  whether  tlie  bone  breaks  before  the 


Fig.    736. 

Fig.  734. — Pott's  fracture.  Fracture  of  inner  m:\lIeolus. 
Fig.  73.5, — Pott's  fracture.  Fracture  of  inner  malleolus. 
Pig.    73G. — Pott's   fracture    with    fracture   of    inner    malleolus. 


Fig.    737. — Pott's   fracture.      Comminution   of   filnila    and   fracture   of   inner   malleolus. 

Fig.   738. — Old  Pott's  fracture.      Incomplete  reduction. 

Fig.   739. — Lateral  view  of  old  Pott's  fracture.      Note  old  fracture  in  fibula. 


ligament  ruptures.     Probably  the  latter  mechanism  obtains  in  most 
cases.     Instances  of  Pott's  fracture  liy  inversion  of  the  foot  have 


664 


FRACTT'RES    AND    DISLOCATIONS 


been  reported  in  wliidi  llu-  sliai't  ol'  tlu'  lihiila  was  i'ractui'etl  by  the 
inward  pull  on  the  external  nuilleoliis,  and  tlu'  inner  malleolus 
fractured  by  direct  pressure  of  the  astrapdus.  The  i)roduetion  of 
Pott 's  fracture  by  this  nieehanisni  is  v<in\  Separation  of  the  lower 
ends  of  the  tibia  and  fibula  have  occurrctl  as  a  result  of  rupture  of 
the  tibio-fibular  ligaments  or  a  wrenching  otf  of  their  ])ony  attach- 
ments, this  condition  however  cannot  he  properly  called  a  Pott's 
fracture.  It  will  be  considered  iiiidci-  dislocations  of  the  ankle. 
When  the  lateral  displacement  of  the  foot  is  great  the  inner 
malleolus  (or  what  is  left  of  it  after  the  tip  has  been  avulsed) 
may  be  forced  through  the  skin,  thus  rendering  the  condition  com- 
pound and  exposing  the  ankle-joint  to  infecticn. 


Fig.  740. — Pott's  fracture  of  the  left  iiiikle  ii  few  minutes  following  injury.  De- 
formity moderate  though  characteristic.  Xote  the  outward  displacement  of  the  foot  and 
the  prominence  of  the  inner  malleolus.  The  difference  in  the  contour  of  the  two  ankles 
may  be  readily  recognized  even  though  the  shoe  on  the  right  foot  has  not  been  removed. 
Inner  arrow  points  to  ruptured  deltoid  ligament.  Outer  arrow  indicates  level  of  fibular 
fracture. 


An  "inverted"  or  "reverse"  Pott's  fracture  is  an  inward  frac- 
ture-dislocation of  the  ankle  and  will  be  discussed  under  the  head- 
ing of  "Dislocations  of  the  Ankle,"  on  page  684.  The  treatment 
of  this  condition  is  essentially  different  from  that  of  Pott's  fracture 
and  the  two  lesions  should  not  be  confounded. 

Symptoms. — Immediate  and  complete  loss  of  function,  pain  and 
characteristic  deformity,  following  an  injury  to  the  ankle,  are  the 
typical  symptoms  occurring  in  Pott's  fracture.  The  foot  is  in  a 
position  of  more  or  less  pronounced  eversion  and  the  inner  malleolus 
is  more  prominent  than  normal.     It  is  often  impossible  to  elicit 


pott's  fracture 


665 


crepitus  but  abnormal  rno))ility  will  l)e  recognized  when  the  lateral 
stability  of  the  ankle  is  tested.  If  the  foot  is  viewed  laterally  an 
abnormal  prominence  of  the  heel  will  usually  be  noted  and  the 
dorsum  of  the  foot  will  be  found  somewhat  shortened.     Measure- 


rig.  741. 


Fig.   742. 

Figs.  741  and  742. — Simple  Pott's  fracture  the  result  of  a  fall  on  the  foot.  Note 
prominence  in  region  of  internal  malleolus  and  eversion  of  ankle,  which  is  present  in 
both  upright  and  recvimbent  positions.  Note  also  depression  about  one  inch  above 
external  malleolus  which  corresponds  to  fracture  in  fibula.  Photographed  about  twenty 
minutes  following  accident. 


ments  should  be  made  from  the  anterior  edge  of  the  lower  tibial 
articular  surface  to  the  base  of  the  phalanx  of  the  great  toe,  and 
compared  with  the  opposite  foot.  Swelling  follows  the  injury 
rapidly  and  tends  to  mask  the  deformity.     The  ankle-joint  becomes 


666 


FRACTURES  AND   DISLOCATIONS 


distended  with  blood  and  synovial  fluid.  Tlie  mtire  ankle  is  ten- 
der and  ])ainfnl,  especially  in  tiie  rejiion  of  tlu-  lilmlar  fracture  and 
below  the  internal  malleolus.  Ecehymosis  usually  develops  within 
the  first  twelve  or  twenty-four  hours.  If  the  fracture  is  allowed 
to  go  untreated  or  if  the  condition  is  not  projx'i'ly  diagnosed  and 
the  deformity  fully  corrected,  recovery  takes  i)lace  with  the  foot 
in  eversion  and  backward  displacement.  Tliis  nieaiis  lii'eat  and 
permanent  loss  oj"  ruiiclion.  There  are  two  eleuients  in  the  de- 
formity; Hr.stl\-.  tile  cvcision  of  the  foot  and  secondlv,  the  back- 


Fig.'  743. — -Vnotlur  view   of   the  cuse  shown   in   Figs.   741   :\n.\   1  il. 

ward  displacement,  both  of  which  tend  to  recur  as  soon  as  the  parts 
are  released. 

Diagnosis. — There  should  be  little  difficulty  in  recognizing  the 
condition,  especially  if  seen  before  the  swelling  has  become  pro- 
nounced. The  deformity  is  characteristic,  as  shown  in  the  accom- 
panying illustrations.  The  eversion,  backward  displacement,  ab- 
normal mobility,  pain,  loss  of  function  and  sometimes  crepitus 
should  enable  one  to  recognize  the  condition  as  soon  as  seen.  An 
X-ray  plate,  how^ever,  is  of  great  value  in  determining  the  details 
of  the  injury  and  the  presence  of  unusual  complicating  fractures 
when  they  occur.     It  is  of  especial  importance  in  ascertaining  the 


POTT  S  FRACTURE 


667 


position  of  the  fragments  after  rednction  has  been  attempted.  As 
previously  stated  the  traumatic  intiammatory  reaction  tends  to 
mask  the  deformity,  yet  the  disturbed  alignment  is  generally  ap- 
parent even  when  the  swelling  is  extreme.  In  the  usual  supra- 
malleolar fracture  the  break  in  the  tibia  may  be  recognized  above 
the  ankle-joint,  and  the  malleoli  are  not  spread  as  in  Pott's  frac- 
ture.    In  longitudinal  splitting  of  the  lower  end  of  the  tibia  the 


Fig.    744. 


Pig.    745. 

Figs.  744  and  745. — Recent  Pott's  fracture  seen  from  behind.  Note  the  outward 
displacement  of  the  foot  and  the  prominence  of  the  inner  maheolus.  Deformity  cor- 
rected by  drawing  the  foot  inward  and  forward. 


diagnosis  is  sometimes  difficult  without  the  aid  of  the  X-ray  al- 
though it  will  often  be  possible  to  elicit  an  abnormal  mobility  not 
seen  in  Pott's  fracture. 

Splitting  off  of  a  small  portion  of  bone,  including  the  tibial  at- 
tachment of  the  lower  tibio-fibular  ligaments  and  a  part  of  the 
lower  tibial  articular  surface,  may  permit  of  independent  motion 
between  the  malleoli,  but  is  often  particularly  difficult  to  recognize 
unless  a  Rontgenogram  is  made. 


668  FRACTURES    AM)    nisi.oCATIOXS 

There  is  no  distinction  to  l)e  made  between  outward  dislocation 
of  the  foot  and  Pott's  fraeture;  they  ai-e  jiraetieally  the  same  con- 
dition. In  inward  dislocation  of  the  ankle  tlie  foot  is  displaced 
inwai'd  and  tlie  accomiianyini;:  fracture  in  the  tibula  is  at  a  lower 
level,  wliik'  the  fractui'c  in  tlie  tibia  is  at  a  hipher  level,  than  is 
seen  in  Pott's  fracture.  In  forwai'd  dislocations  the  foot  is  dis- 
placed forward  and  in  backward  luxations,  liackwai'd  instead  of 
the  tyincal  outward  dis])lacenu^nt  accomi)anying  Pott's  fi-acture. 

In  some  instances  the  characteristic  deformity  of  Pott's  may  be 
absent  because  of  the  ankle  having  been  pulled  back  into  position 
before  the  surgeon  sees  the  case.  The  lateral  stability  of  the  ankle, 
however,  is  destroyed  and  when  an  attempt  is  nuide  to  displace  the 
foot  outward  this  fact  is  recognized  and  the  typical  deformity  is 
produced. 

Treatment. — The  indications  in  the  treatment  of  Pott's  fracture 
are  to  correct  the  eversion  and  backward  displacement  of  the  foot, 
and  to  see  to  it  that  these  two  deformities  are  completely  reduced 
and  maintained  in  2DO.sition  until  the  callus  formation  and  liga- 
mentous repair  are  suf^eiently  strong  to  prevent  recurrence. 

As  an  emergejiey  method  Dupuytren's  splint  is  particularly  sat- 
isfactory but  should  be  replaced  by  Stimson's  plaster  splints  within 
a  week. 

The  deformity  should  be  corrected  as  soon  a.s  possible  and  meas- 
ures instituted  to  control  the  intiammatory  reaction  which  is  to 
follow. 

The  recumbent  position,  elevation  of  the  injured  foot  and  the 
intermittent  use  of  the  ice  cap  over  the  seat  of  fracture  will  relieve 
the  pain  and  control  the  swelling.  If  the  trauii\a  producing  the 
injury  was  severe  and  the  swelling  is  great  it  may  be  best  to  treat 
the  fracture  on  a  pillow  splint  for  the  first  few  days. 

Dupuytren's  splint. — A  board  as  broad  as  the  calf  of  the  leg,  and 
from  one-fourth  to  tive-eighths  inches  in  thickness  extends  from 
below  the  knee  to  a  point  a  few  inches  below  the  foot.  It  is  heavily 
padded  above  the  fracture  with  a  folded  sheet  of  sufficient  thick- 
ness to  allow  complete  inversion  of  the  foot  without  the  latter 
touching  the  splint  (see  Fig.  746).  The  lower  end  is  notched  so 
that  turns  of  bandage  may  be  secured  to  the  end  of  the  splint.  The 
splint  is  fastened  to  the  leg  with  bandages  or  strips  of  adhesive,  the 
foot  forced  into  inversion  and  held  in  position  as  shown  in  the  ac- 
companying illustrations.     In  this  way  the  outward  displacement 


POTT 'S  FRACTURE 


669 


is  corrected  and  maintained  in  rednction.  The  backward  deformity 
is  more  difficult  to  correct  when  this  splint  is  employed.  The  foot 
should  be  pulled  forward  as  the  bandages  are  being  applied,  but 
the  risk  of  subsequent  backward  slumping  of  the  foot  is  consider- 
able and  requires  constant  watching.  This  method  is  of  value  as 
an  emergency  dressing,  especially  since  the  necessary  materials  are 
readily  obtainable  under  almost  all  circumstances.  After  the  splint 
is  applied  the  patient  should  remain  in  the  recumbent  position  with 
the  injured  member  elevated  on  a  pillow  and  the  ice  cap  applied. 
The  change  in  the  size  of  the  parts  as  a  result  of  swelling,  renders 
it  inadvisable  to  employ  a  plaster  dressing  early  in  the  treatment 
of  Pott's  fracture. 


Fig.  746. — Shows  the  making:  and  use  of  Dupuytren's  splint  for  the  treatment  of 
Pott's  fracture.  This  splint  is  most  satisfactory  as  an  emergency  measure  and  during 
the  acute  traumatic  reaction.  A.  shows  board  with  notched  lower  end.  B.  shows  pad- 
ding applied,  which  is  thickest  at  ankle.  C.  shows  same  bandaged  in  position.  D.  shows 
lower  extremity  in  proper  relation  with  splint.  E.  shows  foot  forced  into  adduction.  F. 
shows  bandages  applied.  Some  of  the  turns  passing  over  the  foot  are  caught  in  the 
notched  end  of  the  splint,  thus  rendering  adduction  more  firm.  If  the  traumatic  re- 
action is  extreme  it  may  lie  best  to  dispense  with  all  forms  of  bandaging  and  treat  tho 
lest  in  a  fracture-box  or  on  a  pillow  splint  for  the  first  few  days.  (See  Figs.  698  to 
702  and  707.) 

The  Cahot  posterior  wire  splint  with  side  splints  is  a  satisfactory 
dressing  both  in  the  early  and  late  stages  of  the  treatment  of  this 
fracture  and  has  been  used  with  considerable  success  by  some  sur- 
geons. In  the  early  stages,  however,  it  has  no  advantage  over 
Dupuytren's  splint  and  interferes  someAvhat  with  the  application 
of  the  ice  cap.  In  the  later  stages  it  is  not  as  perfect  a  method  as 
is  that  of  Stimson,  in  which  the  lateral  and  posterior  plaster  splints 
are  used. 

Stimson' s  plaster  splints  constitute  the  most  satisfactory  perma- 
nent dressing  known  for  the  treatment  of  Pott's  fracture.  The  pos- 
terior splint,  which  is  applied  first,  extends  down  the  back  of  the 


670 


FRACTURES   AND   DISLOCATIONS 


loii:  and  lit'el  ami  uiidn-  the  sole  of  tlio  foot  to  tlio  toes.  Tlic  lateral 
si)liiit  siioiiUl  cxtciul  Troiii  .-iliout  tlic  ii|)|)('i'  end  of  tln'  lilmla,  down 
tlio  external  iispeet  of  tlic  lei;-,  iiiidiM-  llic  sole  oT  llie  Toot,  oxcv  llic 
dorsum  to  the  cxtcni;!!  iiudlfoliis.  Tlu'sc  splints  .-irc  lies!  iimdc  of 
ofanzo  folded  and  cut  to  tln'  pn>|i('i'  Icii^lli  and  aliout  lour  inches 
in  width.     If  a  t  went  \'-ti\('  \ai'd   holt   of  uau/.c,  sndi  as  is  fonnd   in 


Figs.  747  and  748. — Htinison's  phistor  si)liiits  a])i)lied  to  a  Fott'.s  fracture  and  held 
in  position  by  strips  of  adhesive  ijlaster.  Note  how  the  foot  has  been  inverted  and 
brought  forward  until  the  relations  are  normal.  Resiilts  in  this  case  were  complete 
restoration   of   funftion    and    absence   of  deformitv. 


the  usual  hospital  supplies  is  available,  the  desired  amount  may 
be  cut  from  it  without  Maste  and  each  splint  is  thus  made  of  one 
piece.  Each  splint  should  he  from  twelve  to  eighteen  ply,  according 
to  the  size  and  musculature  of  the  patient.  These  stri{)s  of  gauze 
are  soaked  in  plaster  cream,  w'rung  out  and  placed  in  proper  posi- 
tion on  the  leg.     The  posterior  splint  is  applied  first  and  then  the 


pott's  FRACTURE  671 

lateral  splint.  The  lower  end  of  tlie  lateral  splint,  encircling-  the 
foot,  should  he  overlapped  by  the  straight  portion  on  1lic  onlcr 
aspect  of  the  ankle  (see  Fig.  748).  Tlic  splints  arc  placed  in  posi- 
tion and  brought  (piickly  into  snug  position  by  a  roller  bandfige. 
The  surgeon  then  takes  his  phice  at  the  foot  of  tlu^  table  and  forces 
the  foot  forward  and  into  adduction  while  the  f)laster  is  still  wet. 
This  attitude  is  maintained  until  the  plaster  lias  set  sufficiently  to 
maintain  the  proper  reduction.  During  this  time  the  weight  of  the 
foot  and  lower  extremity  rests  on  the  heel  in  the  surgeon's  hand 
thus  forcing  the  foot  forward  and  correcting  the  usual  backward 
displacement.  Some  cases  may  require  more  force  than  is  exerted 
by  the  weight  of  the  limb  in  overcoming  this  posterior  deformity. 
A  quick-setting  plaster  should  be  used,  otherwise  the  holding  of 
the  foot  in  inversion  will  be  unduly  tedious.  If  the  condition  is 
compound  the  lateral  splint  may  be  applied  to  the  inner  side  of 
the  leg  with  equal  efficiency.  If  gauze  is  not  at  hand  the  splints 
may  be  made  of  four-inch  plaster  bandages  soaked  in  water  and 
run  back  and  forth  on  a  table  until  the  proper  thickness  has  been 
attained. 

It  should  be  remembered  in  reducing  an  ordinary  Pott's  frac- 
ture that  the  deformity  cannot  be  over-corrected. 

An  anesthetic  is  always  advisable  in  reducing  the  deformity  and 
in  the  application  of  a  permanent  dressing,  unless  some  constitu- 
tional condition  exists  to  act  as  a  contraindication. 

Following  reduction  a  Rontgenogram  should  be  taken  to  verify 
the  position  of  the  fragments. 

The  usual  Pott's  fracture  can  be  reduced  wdthout  difficulty  as 
just  described ;  occasionally  complications  exist  such  as  the  interpo- 
sition of  a  fragment  between  the  astragalus  and  the  inner  malleolus, 
which  render  reduction  without  operation  impossible. 

Operative  Treatment. — The  open  method  is  indicated  when  good 
reduction  cannot  be  accomplished  by  non-operative  methods  or 
when  the  fracture  is  compound  from  the  first.  If  reduction  has 
been  attempted  and  failed,  the  X-ray  will  usually  reveal  the  cause 
of  the  failure,  if  it  has  not  already  been  learned  through  palpa- 
tion and  inspection.  If,  after  complete  inversion  has  been  accom- 
plished, the  upper  end  of  the  fibular  fragment  remains  displaced 
inward  against  the  tibia  and  there  is  undue  space  between  the  ex- 
ternal malleolus  and  astragalus,  it  will  be  advisable  to  make  an 
incision  over  the  fibular  fracture,  engage  the  fractured  surfaces 


672  FRACTURES   AND   DISLOCATIONS 

and  secure  the  fibula  in  proper  alignment.  If  internal  fixation  is 
found  necessary  to  maintain  reduction  a  Lane  plate  or  wire  may 
be  us(_'d.  If  .this  inward  displacement  of  the  upper  end  of  the 
lower  fibular  fragment  is  allowed  to  persist  it  means  a  widening  of 
the  mortise  by  outward  displacement  of  the  external  nudleolus, 
and  a  weak  ankle  will  I'csult.  The  interposition  of  a  fragment  be- 
tween the  inner  malleolus  and  astragalus  calls  for  removal  of  the 
obstructing  material.  This  is  best  accomplished  through  a  longi- 
tudinal incision  below  the  inner  malleolus.  With  the  parts  exposed 
tlir  iitiici-  lateral  ligament  should  be  sutured  before  the  incision  is 
closed. 

Operation  is  sometimes  called  for  because  of  loss  of  function  and 
painful  joint  following  an  imperfectly  reduced  Pott's  fracture. 
When  a  patient  presents  himself  for  treatment  under  these  circum- 
stances the  case  should  be  carefully  studied  by  the  usual  examina- 
tion and  the  X-ray  before  an  opinion  or  advice  is  given.  The 
exact  cause  of  the  disturbed  function  should  be  accurately  ascer- 
tained, and  then,  if  surgical  intervention  offers  relief,  the  parts 
should  be  opened.  The  usual  causes  of  loss  of  function  are  trau- 
matic flat-foot  and  backward  displacement  of  the  foot.  Both  of 
these  conditions  can,  as  a  rule,  be  corrected  by  osteotomies  or  read- 
justment of  the  articular  surfaces.  The  joint  is  best  approached 
through  two  longitudinal  incisions  over  the  malleoli.  Through  the 
iiuier  incision  obstructing  materials  such  as  bone  or  periosteum  may 
be  removed  from  between  the  astragalus  and  inner  malleolus. 
Through  the  outer  incision  the  position  of  the  external  malleolus 
may  lie  corrected,  if  in  deformity,  and  an  osteotomy  of  the  fibula 
above  the  tibio-fibular  ligaments  may  be  performed  if  found  neces- 
sary to  bring  the  malleolus  back  into  position.  Obstructing  fibrous 
tissue  should  be  removed  if  present.  The  common  method  of  cor- 
recting an  old  Pott's  fracture  deformity  is  by  a  double  osteotomy 
of  the  tibia  and  fibula  above  the  ankle.  By  this  means  the  foot  and 
ankle  are  brought  back  into  proper  alignment  with  the  leg  and 
both  the  outward  and  the  backward  displacements  are  corrected. 

If  the  fracture  is  compound  the  lacerated  edges  should  be  ex- 
cised, the  wound  and  joint  cavity  thoroughly  washed  with  a  few 
gallons  of  physiological  sterile  salt  solution  and  the  parts  closed. 
If  infection  follows  in  spite  of  this  treatment  the  joint  should  be 
injected  with  IMurphy's  glycerine-formaline  solution  and  the  con- 
dition treated  according  to  the  principles  laid  down  under  the  head- 


pott's  FRACTURE  673 

ing  of  "Compound  Dislocations "  on  page  789.  If  tiie  case  is  seen 
early  and  the  treatment  just  mentioned  followed  it  will  usually  be 
possible  to  obtain  aseptic  healing  even  though  the  fracture  is  badly 
compounded.  Following  operation  splints  should  be  applied  as 
already  described. 

After-Treatment. — In  the  usual  case  of  simple  Pott's  fracture  the 
ankle  should  be  maintained  in  adduction  for  a  period  of  six  weeks. 
No  weight  should  be  borne  on  the  injured  foot  within  two  months 
of  the  time  of  the  fracture.  Massage  of  the  leg,  especially  the  calf 
muscles,  is  of  advantage  after  the  first  week  but  it  is  best  not  to 
remove  the  splints  early  in  the  after-treatment  lest  recurrence  of 
deformity  take  place. 

There  is  a  marked  tendency  to  the  development  of  flat-foot  fol- 
lowing Pott's  fracture  and  it  is  due  to  incomplete  reduction  of  the 
displacement  or  the  too  early  use  of  the  foot  in  bearing  the  weight 
of  the  body.  Two  months  is  a  longer  period  than  is  usually  ad- 
vised before  weight  is  borne  on  the  foot,  yet  the  author  has  found 
that  if  this  length  of  time  is  allowed  before  the  parts  are  subjected 
to  strain,  the  patient  does  not  develop  flat-foot.  The  use  of  arch 
supports  in  the  late  after-treatment  is  an  admission  in  itself  that 
weight  is  being  borne  on  the  foot  too  soon.  Passive  motion  of  the 
foot,  however,  should  be  begun  early  but  must  be  guarded  lest  out- 
ward strain  be  placed  on  the  ankle.  The  foot  should  be  carried 
through  dorsal  and  plantar  flexion  but  eversion  must  not  be  made. 
By  means  of  massage,  hot  applications  and  passive  motion  the  func- 
tion of  the  joint  should  be  well  restored  before  the  patient  is  al- 
lowed to  bear  his  weight  on  the  member  in  walking.  Passive  mo- 
tion should  be  applied  to  the  joints  of  the  tarsus  as  well  as  to  the 
ankle-joint  proper,  so  that  the  full  flexibility  and  usefulness  of  the 
foot  may  be  restored. 

Prognosis. — If  proper  reduction  is  accomplished  and  sufficient 
time  is  allowed  for  the  solid  repair  of  bone  and  ligament,  in  a 
healthy  adult,  the  joint  should  be  practically  as  useful  and  strong 
as  before  the  injury.  The  older  the  patient,  the  longer  the  conva- 
lescence and  the  more  incomplete  the  restoration  of  function.  A 
certain  amount  of  restriction  of  motion  is  common  following  this 
fracture  and  seems  to  be  unavoidable.  Cases  in  which  accurate 
reduction  has  been  accomplished  and  early  passive  motion  insti- 
tuted, show  the  greatest  freedom  of  motion  when  recovery  is  com- 
plete.    Extreme  dorsal  flexion  is  the  motion  most  commonl}^  re- 


674  FKACTIRKS    AND    DISLOC.VTIDNS 

strieted  and  the  one  least  essential  in  the  nse  of  the  foot.  Traumatic 
flat-foot  followiuET  T*ott*s  fraetuiv  is  a  serious,  cripplino:  deformity 
and  shows  a  tendrncy  to  ^row  worsi-  wlicii  oiicc  cstaljlishcd.  Con- 
sitii'rahle  relief  may  he  had  hy  the  use  of  oi'thojicdic  ai)i)lianees 
such  as  used  in  the  treatment  of  flat-foot  I'lom  other  causes.  Steel 
or  felt  arches  to  support  the  inner  side  of  the  foot  and  a  hiiildinf? 
\^^  of  the  inner  side  of  the  sole,  may  enable  the  patient  to  get  aboul 
with  more  or  less  ease  if  the  defoi-mity  is  not  too  great. 

Considerable  improvement  will  usually  take  place  during  the 
fii'st  two  or  three  months  of  active  use  and  weight  bearing. 

Loss  of  lateral  nu)tion  in  the  foot  may  be  productive  of  lame- 
ness and  constitute  a  serious  disability.  Lateral  niolion  is  not  one 
of  the  noiMual  actions  of  the  ankle-joint  but  is  accomplished  by  the 
articulations  in  the  tarsus.  It  is  evident  therefore  that  this  condi- 
tion is  not  the  I'esidt  of  the  injury  sustained  by  the  tibio-fibular 
articulation  but  follows  luolonged  iunuobilization  of  the  foot  with- 
out the  necessary  earl}^  passive  motion  to  the  tarsus. 


CHAPTER  XLVII. 

FRACTURES  OF  THE   LOWER  ENDS  OF  THE  TIBIA 
AND  FIBULA. 


Surgical  Anatomy. — The  surgical  anatouiy  of  the  lower  ends  of 
the  tibia  and  tibnla  is  similar  to  that  already  given  under  the  head- 
ing of  "Pott's  fracture"  on  page  659. 

Symptoms. — When  both  bones  are  fractured  above  the  ankle,  pain, 
loss  of  function,  crepitus,  abnormal  mobility  and  swelling  are 
usually  present  and  well  marked.  The  traumatic  reaction  is  often 
less  pronounced  than  that  accompanying  the  usual  fracture  of  the 


749. 


Fig.    750. 


749. — Splitting  of  lower  end  of  tibia. 
750. — Splitting  of  lower  end  of  tibia. 


shaft  and  the  mobility  is,  as  a  rule,  not  so  completely  flail-like. 
The  line  of  fracture  in  the  lower  end  of  the  tibia  is  cpiite  variable 
and  accordingly  the  deformity  is  not  characteristic.  The  frac- 
ture may  be  transverse,  spiral,  comminuted  or  longitudinal.     Longi- 

675 


676 


FRACT^RE^^    AND    DISLOCATIONS 


Fis.   75 1 


Fig.    751. — Fracfui-e    of    tip    of    intern  ill    malleolus. 

Fig.    752. — Fracture  of   internal  malleolus  at   higher  level. 

Fig.    753. — Fracture  of  internal  malleolus  at  still  higher  level. 


Fig.  754. — EpiphvM-ul  supination  of  lower  tnil  ul  liliiii  cuniplicated  b.v  friicture  of 
tibial  diaphysis.  Also  fracture  of  tiljula.  The  result  of  violence  similar  to  that  pro- 
ducing Pott's  fracture. 


FRACTURES    OP   LOWER    ENDS    OF    TIBTA    AN[~)    FIBULA 


677 


tudinal  splitting  of  the  lower  end  of  the  tibia  ciitei-iiif^-  llic  joint 
cavity  is  not  at  all  uneoininon  and  is  nsualiy  aecoiiipMiiied  l)y  trans- 
verse thickening  of  the  ankle.  Tlie  line  of  fraeture  may  extend 
from  the  inner  surface  of  th(;  bone  into  tlie  joint  cavity  so  that 
the  inner  malleolus  is  displaced  inward  or  it  may  extend  from  the 
outer  surface  of  the  hone  into  the  articulation  and  allow  the  frag- 


Fig.   756. 

Figs.    755   and  756. — Fracture  of  both  bones  of  tlie  leg  just  above  the  ankle.      Arrows 
indicate  the  levels  of  the  two  fractures. 


ment  and  lower  end  of  the  fibula  to  be  displaced  outward.  Diastasis 
of  the  lower  tibio-fibular  articulation  with  separation  of  the  lower 
ends  of  the  bones  of  the  leg  is  occasionally  seen  and  has  been  classi- 
fied as  a  complication  of  upward  dislocation  of  the  ankle  when  the 
astragalus  is  displaced  upward  between  the  ends  of  the  bones. 
Supra-malleolar  fracture  of  the  tibia  is  usually  accompanied  by 
fracture  of  the  lower  end  of  the  fibula.     Fracture  of  the  inner 


HTS 


FRAOTITRES    AND    DISLOCATTONS 


malleolus  usually  occurs  as  a  i)ai't  of  Pott's  fracture,  but  even  as 
au  isolated  injury  it  is  not  uncoimnon.  A'arious  types  of  fracture 
of  the  lower  ends  of  the  tibia  and  iibula  occur  as  complications  of 
dislocations  of  the  ankle  and  of  Pott's  fracture,  but  will  not  be 
considered  undei*  this  heading.  It  is  not  at  all  uncommon  to  see 
cue  of  the  tibial  fragments  projecting  through  the  .skin.     The  de- 


ymmmmm^/tiiki!iiii:iiaf. 


Pigs.  757  iind  758. — Supraiuiilleolav  fracture  of  both  bones  witli  inward  displace- 
ment of  the  foot.  Compare  the  two  ankles.  Arrows  indicate  the  levels  of  the  two  frac- 
tures. 


formity  may  be  pronounced  and  in  cases  resulting  from  direct  vio- 
lence the  fragments  may  remain  in  the  position  in  which  they  were 
driven  at  the  time  of  the  accident.  Fracture  of  the  lower  end  of 
the  fibula  is  often  attended  by  remarkably  slight  loss  of  function 
especially  if  the  line  of  fracture  is  into  the  lower  tibio-fibular  ar- 
ticulation. The  patient  may  be  able  to  walk  with  such  a  fracture 
although  use  of  the  member  entails  pain. 


FRACTURES    OP   LOWER   ENDS    OP    TIBIA    AND    FIBULA 


679 


Diagnosis. — There  should,  as  a  rule,  be  liit](i  (lifficully  in  recog- 
nizing fractures  in  this  region  but  the  details  of  the  break  are 
often  difficult  or  impossible  to  recognize   without   the  aid   of  the 


Fiff.    759. 


Figs.  759  and  760. — Fracture  of  both  bones  of  the  leg  just  above  the  ankle  with 
pronounced  inward  displacement  of  the  foot.  The  photographs  were  taken  about  twenty 
minutes  following  injury  and  show  an  unusual  displacement.  I.  indicates  the  upper 
end  of  the  lower  fragment  of  the  fibula.  II.  indicates  the  displaced  external  malleolus. 
III.   indicates  the  internal  malleolus.     Injury  the  result  of  direct  violence. 

X-ray.  Fracture  of  the  fibula  may  be  mistaken  for  a  sprain  unless 
the  examination  is  carefully  made.  When  the  fracture  is  supra- 
malleolar the  two  malleoli  will  remain  in  proper  relation  to  each 
other  but  will  move  with  the  foot  and  not  the  leg.     "When  the  frac- 


680 


FRACTFRES    AXP    DISLOCATIONS 


ture  entiM-s  the  joint  cavity  it  will  usually  he  possibK'  to  elicit  ab- 
noi'iual  mobility  of  one  of  tlie  malleoli  (tlie  one  detached).  The 
symptoms  in  sei)aration  of  the  lower  epiphyses  are  praetieally  the 
same  as  in  fractui-es  of  this  i-ewion  except  for  the  crepitus  which  is 


Fig.    762. 

Figs.  761  and  762. — Splitting  of  the  lower  end  of  the  tibia  with  broadening  of  the 
iinklf.  Both  malleoli  prominent.  Type  of  case  requiring  operation  to  secure  the  best 
results. 


cartilaginous  and  not  bony.  If  the  fracture  in  the  fibula  is  above 
the  lower  tibio-fibular  ligaments  pressure  in  the  middle  of  the  shaft 
will  produce  pain  at  the  seat  of  the  fracture.  If  the  fracture  is 
through  the  ligaments  or  below  them  direct   pressure  at  the  site 


FRACTURES   OP   liOWER   ENDS   OP   TIBIA   AND   PIRTJLA  681 

of  the  lesion  will  be  necessary  to  produce  pain.  When  the  fibula 
alone  is  fractured  there  is  usually  little  loss  of  siren gtli  in  the 
ankle. 

Treatment. — In  fracture  of  both  bones  above  the  ankle  or  in 
epiphyseal  separations  the  indications  in  treatment  are  similar  to 
those  cases  just  described  in  which  the  fracture  is  at  the  usual  site 
(the  junction  of  the  middle  and  lower  thirds  of  the  shafts).  The 
necessity  for  temporary  treatment  is  not  as  great  in  this  region 
since  the  traumatic  reaction  is  seldom  as  severe  as  in  fracture  of 
the  shafts.  It  is  best,  however,  to  place  the  leg  in  a  fracture-box 
or  pillow  splint  for  the  first  few  days,  until  the  amount  of  swelling 
to  follow  can  be  determined.  During  this  time  the  ice  cap  locally 
and  intermittently  applied  is  of  great  value.     A  plaster  stirrup  as 


Pig.  763. — Old  case  of  fracture  of  both  bones  of  the  leg  above  the  malleoli.  PatieiU 
presents  himself  for  treatment  because  of  inability  to  use  limb.  Pen  outline  on  skin 
indicates  palpation  of  fibula.  This  case  is  a  good  example  of  delayed  restoration  of 
function  due  to  incomijlete  reduction  of  fragments. 

already  described  in  "Fractures  of  the  Shaft"  will  in  most  cases 
be  found  thoroughly  efficient  in  maintaining  reduction.  A  quick 
drying  plaster  should  be  used  and  the  surgeon  should  hold  the 
ankle  in  reduction,  while  the  splint  is  setting.  The  best  position 
for  the  ankle,  in  a  given  case,  is  the  one  in  which  the  tendency  to 
recurrence  of  deformity  is  least.  It  is  preferable  to  fix  the  foot 
in  a  position  of  slight  plantar  flexion  rather  than  at  a  right  angle. 
The  proper  position  for  the  foot,  aside  from  the  prevention  of 
deformity,  is  one  in  which  the  flexor  and  extensor  muscles  are  at 
an  equal  tension  and  balance  each  other.  In  instances  in  which 
the  lower  end  of  the  tibia  is  split  longitudinally  it  will  often  be 


682  FRACTURES  AND  DISLOCATIONS 

uecessaiy  to  force  the  fraguieuts  together,  by  hiteral  pressure,  while 
the  plaster  is  drying,  in  order  that  union  may  not  take  place  with 
transverse  thickening  of  the  ankle  and  widening  of  the  mortise. 
If  the  posterior  portion  of  the  articular  surface  of  the  tibia  is 
broken  off  the  foot  should  be  more  or  less  dorsally  flexed  to  favor 
reduction  and  prevent  recurrence.  When  a  fragment  is  broken 
oft'  of  the  articular  surface  anteriorly  the  foot  should  be  immobilized 
in  the  opposite  position  for  the  same  reasons.  The  foot  should  be 
covered  with  a  layer  or  two  of  sheet  cotton  before  the  stirrup  is 
applied.  The  bony  prominences  about  the  ankle  are  subcutaneous 
and  if  the  splint  is  not  properly  padded  undue  pressure  may  pro- 
duce sloughing  of  the  skin.  Fracture  of  the  fibula  alone  does  not 
require  as  solid  immobilization  as  is  the  case  in  isolated  fracture 
of  the  lower  end  of  the  tibia  or  when  both  bones  are  broken. 

When  an  outward  displacement  of  the  external  malleolus  exists 
as  a  result  of  fracture  of  the  fibula,  whether  the  break  is  above, 
below  or  through  the  lower  tibio-fibular  ligaments,  the  deformity 
should  be  corrected  and  held  in  position  by  the  dressing.  Strong 
adduction  of  the  ankle,  as  in  the  treatment  of  Pott's  fracture,  will 
usually  correct  this  displacement  if  the  internal  malleolus  is  intact. 

Operative  Treatment. — Open  treatment  is  not  as  frequently 
indicated  in  fractures  of  the  lower  ends  of  the  tibia  as  it  is  when 
the  shafts  of  these  bones  are  broken.  It  is  most  commonly  called 
for  when  there  is  a  longitudinal  splitting  of  the  lower  end  of  the 
tibia  in  which  difficult}'^  is  experienced  in  approximating  the  frag- 
ments. Even  a  slight  spreading  of  the  malleoli  means  a  widening 
of  the  mortise  in  which  the  trochlear  surface  of  the  astragalus 
rests  and  this  condition,  if  not  corrected,  is  followed  b}^  a  pro- 
tracted recovery  if  not  permanent  disability.  If  two  longitudinal 
incisions  are  made,  one  on  the  inner  and  the  other  on  the  outer 
aspect  of  the  lower  part  of  the  leg,  the  fragments  can  be  replaced 
by  direct  manipulation  and  transverse  holes  drilled  through  the 
approximated  fragments  at  the  most  advantageous  points.  Heavy 
wire  is  then  threaded  through  these  holes  and  the  ends  securely 
twisted  to  maintain  proper  reduction.  In  some  instances  passing 
wire  around  the  fragments  may  be  all  that  is  required  but  this 
point  can  seldom  be  determined  until  the  fragments  are  exposed. 
In  supra-malleolar  fractures  open  incision  ma}^  be  necessary  to 
effect  reduction  but  it  is  seldom  necessary  to  employ  internal 
fixation. 


FRACTURES   OF   LOWER   ENDS   OF   TIBIA   AND   FIBULA  683 

After- Treatment. — If  the  traumatic  reaction  is  great  the  leg 
should  be  treated  on  a  pillow  splint  or  in  the  fracture-hox  during 
the  first  few  days.  The  swelling  is  usually  less  than  that  seen  when 
the  fracture  is  higher,  and  it  will  seldom  be  necessary  to  wait  more 
than  four  or  five  days  before  placing  the  leg  in  a  permanent  splint. 
As  previously  stated,  the  plaster  stirrup  is  the  most  efficient  form 
of  permanent  dressing  in  which  to  treat  fractures  in  this  region. 
Union  may  be  expected  in  the  healthy  adult  in  six  weeks  but  the 
callus  is  not  sufficiently  strong  at  this  time  to  permit  of  weight 
bearing.  Massage  and  gentle  passive  motion  should  be  instituted 
at  the  end  of  the  second  week.  During  the  eighth  and  ninth  weeks 
weight  bearing  should  be  gradually  increased  until  the  patient  is 
able  to  walk  at  the  end  of  two  and  a  half  months.  The  time  should 
be  prolonged  in  cases  in  which  the  fracture  involves  the  articular 
surfaces  and  when  passive  motion  is  employed  due  regard  should 
be  had  for  the  tendency  to  displacement,  if  such  exists.  It  is  best 
for  the  patient  to  walk  with  a  cane  for  some  time  following  the 
removal  of  all  dressings.  Persistent  swelling  of  the  ankle  should 
be  met  with  massage  and  hot  applications  and,  if  pronounced,  gi^eat 
relief,  may  be  had  by  the  use  of  an  elastic  stocking  during  the 
day.  Isolated  fracture  of  the  fibula  without  displacement  may, 
as  a  rule,  begin  weight  bearing  at  the  end  of  three  or  four  weeks. 

Prognosis. — The  more  accurate  the  reduction  the  more  complete 
and  prompt  is  recovery.  Some  limitation  of  motion  in  the  ankle, 
especially  dorsal  flexion,  is  common,  following  fractures  in  this 
region,  particularly  so  when  the  line  of  fracture  involves  the  ar- 
ticular surface.  Fractures  of  the  fibula  alone  are  usually  followed 
by  complete  restoration  of  function.  The  prognosis  in  other  re- 
spects is  similar  to  that  already  given  in  "Fractures  of  the  Shafts 
of  the  Bones  of  the  Leg,"  page  657. 


CaiAPTER  XIA'lir. 
DISLOCATIONS  OF  'IIIH   ANKLH. 

Surgical  Anatomy, — 'I'lic  Ijoiics  ('ii1t'i'iii<;'  into  tlic  foi-iiuition  of 
the  ankle-joint  and  the  liyanipnts  liokling  these  bones  in  ap{)Osition, 
have  already  been  ineiitioiuHl  in  the  .sur^jical  anatomy  of  "Pott's 
fracture,"  on  page  65!).  The  niaimci'  in  wliidi  \\\r  iiialh'oli  are 
placed  on  cither  side  of  the  botly  of  the  asli-agalus  explains  the 
freipieney  with  which  fracture  complicates  dislocations  of  this  ar- 
ticulation. Xcai-ly  all  the  luxations  of  the  ankle  are  accompanied 
by  fracture  of  either  the  tibia,  fibula  or  astragalus.  One  or  both 
malleoli  may  be  broken  otif  and  displaced  with  the  foot. 

The  bones  of  the  ankle  are  not  deeply  situated  and  it  is  not 
uncommon  to  see  compound  luxations  of  the  ankle.  When  severe 
and  direct  violence  is  applied  to  the  ankle,  the  foot  may  be  torn 
away  from  the  tibia  and  libula  and  displaced  in  any  direction. 
The  greater  the  violence  producing  the  injury  the  greater  the 
probability  of  the  condition  being  compound  and  complicated  by 
fracture  of  the  malleoli  or  astragalus.  In  severe  cases  the  bones 
of  the  foot  may  be  entirely  toi'u  from  the  lowei-  cud  ol'  the  leg 
with  onl}'  the  soft  tissues  connecting  the  two,  ami  a  large  rent  in 
the  skin.  In  such  instances  the  character  of  the  deformity  is  not 
typical  of  any  of  the  forms  of  ankle  luxation  to  be  described. 

The  typical  luxations  of  the  ankle  in  their  order  of  fi'ccpiency 
are:  outward,  inward,  backward,  forward,  and  upward.  It  should 
be  remembered,  however,  that  a  given  luxation  may  present  a  dis- 
placement resembling  two  forms  of  dislocation.  Thus  the  foot  may 
be  displaced  forward  and  inM-ard  so  that  the  defonnity  shows  some 
of  the  characteristics  of  both  the  forward  and  inward  types  of 
dislocation.  In  many  of  these  luxations  (especially  the  lateral 
types)  there  may  be  a  rotary  element  present  in  Avhieh  the  foot  is 
turned  either  inward  or  outward  on  a  more  or  less  vertical  axis. 
This  form  of  displacement  has  been  described  as  a  separate  form 
of  luxation,  and  may  occur  as  such,  but  is  almost  always  secondary 
to  one  of  the  other  dislocations  just  mentioned. 

684 


DISLOCATIONS    OK    THE    ANKLE 


685 


Fie     764 View   of   ligaments   of   foot  from   flbuhir   side.      E.M.,   External   malleolus; 

A.,   Astragalus;    N..   Navicular;    CM.,   Middle   cuneiform;    C.E.,   External  cuneiform;    CaL, 
Ca'lcaneum;    Cub.,  Cuboid. 


Fig  765 — View  of  ligaments  of  foot  from  tibial  side.  Cun.I.,  Internal  Cuneiform: 
A'  Navicular;  A.,  Astragalus;  J.,  Tibia;  CaL,  Calcaneum;  T.P.,  Tendon  of  tibialis 
posticus;   G.,  Groove  for  the  passage  of  the  tendon  of  the  tibialis  posticus. 


686  FKACTl/RES    AND    1)ISI,(  (CATIONS 

In  outward  hi.nifiona  the  lesions  ai-e  soniewhat  variable.  The 
less  severe  forms  of  this  dislocation  are  the  same  as  Pott's  fracture, 
which  has  already  been  described.  AVhen  the  force  which  pro- 
duces Pott's  fracture  continues  to  act,  the  lower  tibio-fibular  liga- 
ments are  either  ruptured,  or  tear  aAvay  their  til)ial  attachment, 
including  a  fragment  of  bone,  and  llic  astragalus  continues  in  its 
outward  course.  If  the  displacement  is  great  enough  to  allow  the 
trochlear  surface  to  clear  the  tibial  articular  surface,  the  astragalus 
will  be  displaced  upward  as  well  as  outward  and  is  described  as 
one  of  the  upward  luxations  of  the  ankle  (Dupuytren's  disloca- 
tion). The  more  ])ronoui)ced  the  lateral  displacement  of  the  ankle 
(until  it  clears  tlic  til)ia )  tlie  greater  the  tendency  of  the  astragalus 
to  rotate  on  a  more  or  less  horizontal  antero-posterior  axis.  When 
this  rotation  occurs  the  foot  corresponds  to  the  position  assumed 
by  the  astragalus.  The  outer  side  of  the  foot  is  raised  and  the 
sole  looks  downward  and  outward.  The  surgical  anatomy  of  this 
fracture  luxation  is  the  same  as  Pott's  fracture  (see  page  659). 

In  inward  luxations  of  the  ankle  ("inverted"  or  "reversed" 
Pott's  fracture)  the  filmla  is  usually  fractured  at  the  level  of  the 
joint  and  the  inner  malleolus  is  broken  off  at  its  base.  The  line 
of  fracture  in  the  tibia  is  usually  oblique,  extending  upward  and 
inward  from  the  junction  of  the  horizontal  and  vertical  portions 
of  the  lower  tibial  articular  surface.  The  usual  position  of  the 
fracture  is  well  illustrated  in  Fig.  753.  The  astragalus  commonly 
show^s  more  or  less  rotation  in  a  direction  opposite  to  that  usually 
seen  in  Pott's  fracture.  The  foot  is  displaced  inward  according  to 
the  degree  of  causative  violence.  Inward  rotation  of  the  foot  is 
particularly  common  in  this  form  of  luxation. 

Backward  luxations  are  extremely  rare  and  almost  invariabh' 
accompanied  by  fracture.  They  may  result  from  extreme  plantar 
flexion  of  the  foot  or  from  a  force  which  drives  the  foot  backward 
when  the  leg  is  fixed.  The  reverse  mechanism  may  obtain  in  which 
the  lower  end  of  the  leg  is  driven  forward  while  the  foot  is  fixed. 
When  this  type  of  luxation  is  the  result  of  extreme  plantar  flexion 
the  posterior  margin  of  the  tibia  is  almost  invariably  broken  off. 
It  is  common  for  one  or  both  of  the  malleoli  to  be  broken  off  and 
displaced  backward  with  the  foot.  The  lower  end  of  the  tibia  rests 
on  the  scaphoid  and  cuneiform  bones  while  the  astragalus  is  dis- 
placed backward.  The  ligaments  of  the  joint  suffer  extensive 
laceration.     If  one  malleolus  and  its  corresponding  lateral  ligament 


DISLOCATIONS   OP   THE   ANKLE  687 

remain  intact  the  backward  displacement  will  be  accompanied  by 
more  or  less  of  a  rotary  deformity  with  the  sound  malleolus  as  the 
center  of  the  arc  described. 

Forward  luxations  are  extremely  rare  and  almost  invariably 
accompanied  by  fracture  of  the  malleoli  or  the  anterior  edge  of 
the  tibia.  This  type  of  dislocation  of  the  ankle  is  produced  by  a 
force  which  drives  the  lower  end  of  the  leg  backward  while  the  foot 
is  fixed,  or  the  same  result  may  follow  a  blow  on  the  heel  which 
drives  the  foot  forward  while  the  leg  is  fixed.  Extreme  dorsal 
flexion,  alone  or  combined  with  an  antero-posterior  force,  may  be 
responsible  for  the  luxation.  When  caused  by  flexion  the  anterior 
edge  of  the  lower  end  of  the  tibia  is  almost  always  broken  off.  The 
reported  cases  of  this  luxation  are  very  few,  being  less  than  fifteen 
in  all  and  have  usually  been  accompanied  by  fracture.  Most  of 
the  uncomplicated  cases  were  reported  before  the  X-ray  came  into 
use  and  some  writers  question  the  occurrence  of  this  luxation  un- 
accompanied by  fracture.  The  case  shown  in  Fig.  768,  however,  is 
a  pure  luxation,  as  demonstrated  by  the  X-ray  plate  which  was 
taken  following  reduction  and  which  showed  no  fracture. 

Upward  luxations  of  the  ankle  are  extremely  rare.  Two  forms 
are  described.  The  first  is  simply  an  exaggerated  Pott's  fracture 
with  diastasis  of  the  lower  tibio-fibular  articulation  and  an  upward 
displacement  of  the  astragalus  between  the  lower  ends  of  the  tibia 
and  fibula.  This  luxation  has  already  been  described  with  out- 
ward dislocations  of  the  ankle  and  is  known  as  Dupuj^tren's  lux- 
ation. The  second  form  of  upward  dislocation  is  one  in  which  the 
astragalus  is  displaced  upward  between  the  lower  ends  of  the  tibia 
and  fibula  following  a  diastasis  of  the  tibio-fibular  joint,  without 
the  usual  complicating  fracture  of  the  fibula. 

Symptoms. — In  all  forms  of  ankle  luxations  the  pain,  tenderness, 
loss  of  function  and  swelling  are  usually  pronounced.  Ecchymosis 
often  develops  within  twelve  to  tw^enty-four  hours  and  is  much 
more  constant  if  the  condition  is  accompanied  by  fracture.  The 
deformity  varies  wdth  the  type  of  luxation. 

In  outivard  luxations  the  appearance  of  the  ankle  is  usually 
typical  of  Pott's  fracture  and  the  exaggerations  of  this  deformity 
just  described. 

In  inward  luxations  of  the  ankle,  the  foot  is  usually  markedly 
inverted  with  more  or  less  adduction.  The  inner  side  of  the  foot 
is  higher  than  normal  while  the  outer  edge  of  the  sole  is  depressed. 


688 


FKACTl'KKS    AND    1)ISI,(  )CATIONS 


'riif  (Irt'oniiity  is  syimiu't rically  opposito  to  that  .seen  in  I'ott's  frac- 
tuir.  W'licii  rotai-y  deformity  accompanies  the  condition  it  is 
usually  inward,  and  may  be  as  much  as  ninety  degrees,  so  the 
toes  point  directly  toward  the  0]iposite  foot. 


Jmu 


Fills.  7(i(i  iiiiil  7()7. — Inward  fractiirc-liixiitinn  nl'  l\\r  .-mkle  :i  few  iiiiinitcs  follow- 
ing tlie  in.iury.  Inner  malleolus  broken  off  and  displaced  with  tlie  foot.  The  external 
malleolus  remains  intact.  Note  the  prominence  of  the  external  malleolus  and  the  way 
the  skin   is  stretched  between  it   and  the  foot.      Reduction   accomplished   without   difficulty. 


Fig.  768. — Anterior  dislocation  of  ankle.  The  entire  nnsns  is  (lisiihiccd  lorward  at 
the  tibio-astragaloid  articulation.  Note  the  prominence  of  the  internal  malleolus  in  its 
backward  displacement.  In.iury  sustained  in  automobile  accident.  Dislocation  caused 
by  VjIow  on  posterior  aspect  of  heel.  Trauma  of  vulnerant  body  was  sufficiently  great 
to  penetrate  counter  of  shoe,  without,  liowever.  injuring  skin  on  heel.  Reduction  easily 
accomplished  by  pressure  in  bend  of  ankle  accompanied  by  traction  on  the  foot.  Picture 
taken  about  two  hours  following  accident.  X-ray  plate  taken  following  reduction  showed 
no  fracture. 


In  haclxivard  dislocations  the  dorsum  of  the  foot  is  shorter  than 
normal  and  the  heel  is  unduly  prominent.  The  foot  is  usually 
held  in  a  position  of  more  or  less  pronounced  plantar  flexion  as  a 
result  of  the  increased  leverage  of  the  muscles  attached  to  the 


DISLOCATION«    OP    TJIE    ANKLE  689 

teiido  Achillis.  A  transverse  ridge  is  felt  anteriorly,  in  tlie  IjcihI 
of  the  ankle,  and  the  extensor  tendons  may  be  palpated  passing 
across  it  from  the  leg  to  the  foot.  If  the  malleoli  are  not  frac- 
tured they  will  be  found  displaced  forward  with  the  leg. 

In  forward  luxations  the  appearance  of  the  foot  and  aiikh'  is 
the  reverse  of  that  just  described.  The  dorsum  of  the  foot  is 
lengthened  and  the  heel  shortened.  The  malleoli  are  both  dis- 
placed backward  unless  broken  off.  The  trochlear  surface  of  the 
astragalus  can,  as  a  rule,  be  felt  in  the  bend  of  the  ankle,  and  when 
the  usual  fracture  is  present  it  may  be  possible  to  palpate  the  de- 
tached tibial  fragment. 

In  upward  luxations  accompanied  by  fracture  of  the  fibula  the 
clinical  picture  is  that  of  an  exaggerated  Pott's  fracture.  Abnor- 
mal lateral  mobility,  broadening  of  the  malleoli,  more  or  less  ever- 
sion  and  crepitus  are  usually  present  on  examination.  The  con- 
dition is  often  compound.  When  upward  luxation  exists  without 
fracture  of  the  fibula  abnormal  lateral  mobility  may  be  absent. 
The  malleoli  are  lowered  (nearer  the  sole  of  the  foot)  and  widely 
separated.     The  leg  above  the  ankle  is  broader  than  normal. 

Diagnosis. — With  a  knowledge  of  the  anatomy  of  the  parts  it  is 
not  difficult  to  recognize  the  different  tjq^es  of  luxation  which 
occur  at  the  ankle.  The  presence  of  complicating  fracture,  how- 
ever, is  often  not  easy  to  determine  without  the  aid  of  the  X-ray. 
If  the  case  is  not  seen  until  some  hours  have  elapsed  following  the 
injury  the  swelling  may  be  so  intense  that  palpation  is  quite  diffi- 
cult. The  disturbance  in  the  alignment  of  the  foot  and  leg,  as 
viewed  from  the  side  and  antero-posteriorly,  should  be  recognized 
by  inspection  even  if  the  swelling  is  pronounced.  Motion  of  the 
foot  will  usually  reveal  the  nature  of  the  injury.  An  X-ray  exam- 
ination of  these  conditions  cannot  be  considered  complete  unless 
two  plates  at  right  angles  to  each  other  are  made. 

Treatment. — The  nature  of  the  injury  should  be  appreciated  by 
the  surgeon  before  an  attempt  at  reduction  is  made.  There  is 
usually  little  difficulty  in  returning  the  articular  surfaces  to  their 
normal  relations  but  when  fracture  complicates  the  condition,  as 
it  frequently  does,  some  trouble  may  be  experienced  in  maintaining 
reduction.  A  short  plaster  stirrup,  as  already  described  in  the 
treatment  of  fractures  of  the  tibia  and  fibula,  is  the  most  satisfac- 
tory method  of  treating  these  luxations  but  the  application  of  this 
dressing  should  be  delaj'-ed  until  the  SAvelling  (if  pronounced)  has 


690  FRACTURES   AND    DISLOCATIONS 

snlisidt'd.  Dui-in^  tliis  time  the  anklo  may  bo  treated  in  the  ])illow 
splint  Of  fraeture-box  with  the  foot  elevated  and  the  ice  cap  ap- 
plied. If  no  fracture  exists  the  most  comfortable  position  for  the 
foot  is  at  an  aniile  of  about  100  decrees  with  the  leg.  In  other 
words  the  foot  should  be  immobilized  in  a  position  a  little  more 
than  a  right  angle.  If  the  anterior  edge  of  the  tibia  has  been  frac- 
tured the  foot  should  be  fixed  in  plantar  tlexion,  if  the  posterior 
edge  is  broken  off  it  should  be  placed  in  dorsal  flexion.  In  fracture 
of  the  malleoli  there  is  usually  little  tendency  to  the  recurrence 
of  deformity  if  good  reduction  has  been  accomplished.  In  the 
treatment  of  Pott's  fracture  the  foot  is  inverted  as  far  as  possible 
and  there  is  no  danger  of  overcorrecting  the  deformity,  but  in 
inward  luxations  of  the  ankle  the  reverse  is  not  true.  The  deform- 
ity can  be  overcorrected  and  if  the  foot  is  put  up  in  extreme  ever- 
sion  the  result  will  be  recovery  with  pronounced  deformity.  The 
reasons  for  this  are  apparent  if  we  note  the  lines  of  fracture  in  an 
inward  luxation  as  compared  with  a  Pott's  fracture.  In  an  inward 
luxation  the  foot  should  be  brought  back  into  alignment  with  the 
bones  of  the  leg  and  fixed  with  a  plaster  stirrup. 

Operative  Treatment. — Operative  treatment  is  usually  not  called 
for  except  in  compound  luxations  and  in  instances  in  which  com- 
plicating fractures  cannot  be  satisfactorily  reduced  by  non-oper- 
ative methods.  The  fragment  of  a  fractured  malleolus  may  become 
displaced  and  wedged  between  the  astragalus  and  end  of  the  tibia, 
requiring  removal  before  proper  reduction  can  be  effected.  If 
one  of  the  malleoli  or  a  portion  of  the  lower  end  of  the  tibia  re- 
mains displaced,  in  spite  of  attempts  at  reduction,  it  may  be  ad- 
visable to  fix  it  in  position  through  an  open  incision. 

Compound  dislocations  of  the  ankle  should  be  treated  along  the 
lines  laid  down  in  the  treatment  of  "Compound  Luxations"  on 
page  789.  The  cavity  of  the  articulation  should  be  irrigated  with 
a  few  gallons  of  sterile  salt  solution,  devitalized  tissue  trimmed 
away  and  the  wound  closed.  PVagments  should  not  be  wired  at 
this  time.  If  internal  fixation  is  found  necessary  it  should  be  per- 
formed at  a  later  date  after  the  primary  wound  has  healed.  If 
severe  infection  develops  ami^utation  may  be  necessary,  especially 
if  the  patient  is  old  and  feeble.  Amputation,  however,  is  rarely 
called  for,  even  in  compound  cases,  if  proper  surgical  measures  are 
carried  out. 

After-Treatment. — The  care  of  these  cases  following  reduction 


DISLOCATIONS   OF   THE   ANKLE  691 

varies  greatly  with  the  complications.  In  simple  dislocations  of 
the  ankle  without  fracture,  ligamentous  union  wili  he  firm  at  the 
end  of  about  three  weeks.  Function  should  be  resumed  gradually. 
Gentle  passive  motion  should  be  begun  at  the  end  of  ten  days. 
When  the  condition  is  complicated  by  fracture  of  the  lower  ends 
of  either  the  tibia  or  fibula  the  after-treatment  will  be  practically 
the  same  as  that  already  given  for  "Pott's  fracture"  (page  673) 
and  in  "Fracture  of  the  Lower  Ends  of  the  Tibia  and  Fibula." 

Prognosis. — In  simple  luxations  the  prognosis  is  good  but  when 
fracture  complicates  the  dislocation  (as  it  almost  invariably  does) 
the  outlook  varies  with  the  nature  of  the  break.  The  prognosis  is 
essentially  that  of  the  complicating  fracture  and  may  be  considered 
the  same  as  set  down  under  "Fractures  of  the  Lower  Ends  of  the 
Tibia  and  Fibula,"  page  683,  and  under  "Pott's  Fracture,"  page 
673. 


CHAPTER  XLiX. 

FRACTURES  AND  DISLOCATIONS  OF  THE 
ASTKACALUS. 

Wlieu  the  astragalus  is  luxated  from  the  iia\i('ular  or  the  eal- 
caneuin,  but  reinaius  in  its  normal  relation  witli  tlie  bones  of  the 
leg,  the  condition  comes  under  the  heading  of  Subastragalar  and 
]Medio-tarsal  Dislocations  (pages  699  and  709).  When  the  as- 
tragalus is  dislocated  from  the  tibia  and  fibula,  but  remains  at- 
tached to  the  tarsal  bones,  the  condition  is  known  as  a  dislocation 
of  the  ankle.  Complete  luxations,  therefore,  are  the  only  displace- 
ments of  this  bone  considered  under  this  heading.  These  may  be 
in  any  direction  but  are  most  comiiioiil\'  forward,  or  forward  and 
outward. 

Surgical  Anatomy. — The  astragalus  is  composed  of  soft  cancellous 
bone  covered  by  a  layer  of  compact  tissue.  The  greater  part  of 
the  surface  of  the  bone  is  taken  up  by  the  articular  surfaces  which 


Figs.  7H9  ;nul  770. — Lateral  and  antero-postorior  views  of  a  fracture-luxation  of- 
the  astragalus.  Fracture  passes  through  neck  of  bone,  the  anterior  fragment  being  dis- 
placed laterally. 

enter  into  the  formation  of  the  calcaneo-astragalar,  astragalo- 
navicular  and  tibio-tarsal  joints.  Above,  it  articulates  with  the 
tibia   and  laterally   the   two   malleoli   extend    downward   and   em- 

ti!l2 


FRACTURES   AND    DISLOCATIONS   OP    ASTRAGALUS 


69.3 


brace  it,  thus  forming  the  firm  compact  mortise  of  the  tibio-as- 
tragalar  articulation  which  allows  of  motion  in  only  one  plane. 
Below,  the  astragalus  presents  two  articular  surfaces  which  entf;r 
into  the  formation  of  the  calcaneo-astragalar  joint.  These  two 
facets  are  separated  by  a  deep  groove  for  the  attachment  of  the 
heavy  interosseous  ligament  which   holds   the   calcaneum   and   as- 


Fig.    771. — Antero  posterior    view    of    outward    luxation    of    astragalus.      The    bone    is 
rotated  on  aii  antero-posterior  axis  as  well  as  being  displaced  laterally. 


tragalus  together.  The  anterior  surface  of  the  astragalus  (the 
head)  projects  forward,  inward  and  downward  and  articulates 
with  the  navicular. 

The  astragalus  is  held  in  position  by  the  conformation  of  the 
bones  surrounding  it  and  the  heavy  ligaments  which  bind  it  to  the 
tibia,  fibula,  calcaneum  and  navicular.  There  are  no  muscular 
attachments  on  this  bone. 


Gi)4  FRACTURES   AND   DISLOCATIONS 

la  ialls  on  llic  loot  tlie  astragalus  may  bu  crushed  between  the 
tibia  and  calcaueuni  and  is  not  infrequently  associated  with  frac- 
ture of  the  latter  bono.  This  type  of  violence,  however,  is  much 
more  likely  to  produce  fracture  of  the  shafts  of  the  bones  of  the 
leg  or  fracture  of  the  os  calcis. 

In  fractures  of  the  body  of  the  astragalus  the  nature  of  the 
break  is  not  constant ;  it  may  be  transverse,  longitudinal,  or  stellate, 
or  the  entire  body  may  be  extensively  crushed  and  comminuted, 
with  a  decrease  in  the  distance  between  the  calcaneum  and  bones 
of  the  leg. 

Fracture  of  the  neck  of  the  astragalus  is  the  most  common  break 
occurring  in  this  bone  and  usually  results  from  extreme  dorsal 
flexion  of  the  foot.  Fractures  of  the  neck  of  the  bone  are  usually 
transverse  and  the  head  is  seldom  much  displaced.  Lateral  lux- 
ations may  occur  with  fracture  of  the  malleoli,  and  backward  dis- 
location of  the  body  of  the  bone  accompanied  by  fracture  of  the 
neck  is  a  condition  which  occurs,  but  is  extremely  rare.  The  soft 
tissues  surrounding  the  ankle  are  scant,  and  in  the  usual  forward, 
or  forward  and  outward  luxation  there  is  scarcely  room  within  the 
skin  to  accommodate  the  bulk  of  the  displaced  bone.  Accordingly 
luxations  of  the  astragalus  are  often  compound.  In  simple  cases 
the  skin  covering  the  displaced  bone  is  rendered  so  tense  that 
slovighing  is  likely  to  follow  if  the  displacement  is  allowed  to  remain 
unreduced.  The  ligamentous  damage  accompanying  luxations  of 
the  astragalus  is  usually  extensive.  The  displacement  of  this  bone 
throws  the  foot  out  of  alignment,  and  the  deformity  will  depend 
largely  on  the  position  occupied  by  the  astragalus.  The  displaced 
bone  may  be  rotated  in  various  directions  depending  largely  on 
the  trauma  which  produced  the  luxation.  Fracture  and  dislocation 
may  both  be  present  in  the  same  case.  In  such  instances  there  is 
usually  a  fracture  of  the  neck  with  luxation  of  either  the  head  or 
body. 

Symptoms. — The  symptoms  accompanying  fractures  and  disloca- 
tions of  the  astragalus  vary  greatly  with  the  nature  and  degree 
of  the  injury.  Fractures  of  this  bone,  especially  of  the  body,  have 
frequently  been  mistaken  for  sprains  of  the  ankle  and  treated  ac- 
cordingly. In  fractures  of  the  body,  pain,  swelling  and  disability 
are  pronounced.  JMotion  of  the  ankle  and  attempts  at  weight  bear- 
ing greatly  increase  the  sutfering.  Crepitus  may,  or  may  not,  be 
present.     It  is  usually  best  elicited  by  palpation  in  the  bend  of 


FRACTURES    AND    DJSLO(JATJONS    Oh'    ASTRAGALUS  695 

the  ankle  while  the  foot  is  being  passively  flexed  and  extended. 
Fracture  of  the  neck  of  the  astragalus  is  usually  attended  by  symp- 
toms a  little  more  pronounced  than  is  the  case  in  fractures  of  the 
body.  Pain,  loss  of  function,  swelling  and  local  tenderness  are 
generally  severe  and  crepitus  is,  as  a  rule,  easily  elicited  by  lateral 
motion  of  the  foot.  Deformity,  if  present  at  all,  is  usually  very 
slight  in  either  fracture  of  the  body  or  neck. 

In  luxations  of  the  bone  loss  of  function,  pain,  swelling  and 
local  tenderness  are  equally  as  pronounced  as  in  fracture,  and  the 
deformity  is  usually  extreme.  In  any  of  the  forward  displace- 
ments the  bone  may  be  felt  as  a  prominent  mass  in  the  bend  of  the 
ankle,  the  foot  is  more  or  less  depressed  and  the  malleoli  are 
lowered.  When  the  astragalus  is  displaced  forward  and  outward 
the  foot  will  be  inverted.  When  the  bone  is  luxated  forward  and 
inward  the  foot  will  be  everted.  In  backward  luxations  of  the  bone 
(practically  always  associated  with  fracture  of  the  neck)  the  body 
may  be  felt  between  the  lower  end  of  the  tibia  and  the  tendo 
Achillis,  and  an  abnormal  hollow  will  be  noted  anteriorly,  below 
the  lower  end  of  the  tibia.  Lateral  luxations  are  associated  with 
fractures  of  one  or  both  malleoli,  are  usually  incomplete  and  re- 
semble lateral  dislocations  of  the  ankle. 

Diagnosis. — The  diagnosis  of  these  different  lesions  is  based  on 
the  symptoms  just  given.  Fractures  of  the  astragalus  are  often 
difficult  to  determine  unless  crepitus  can  be  elicited  and  even  then 
the  surgeon's  appreciation  of  the  condition  is  likely  to  be  vague  if 
the  case  is  not  examined  with  the  X-ray.  The  deformity  in  lux- 
ations is  usually  sufficiently  pronounced  to  permit  of  recognition 
of  the  condition.  The  association  of  fractures  of  the  different 
bones  of  this  region  is  so  frequent  that  the  X-ray  should  be  em- 
ployed whenever  available.  By  its  use  complicating  lesions  are 
often  shown  to  exist,  which  would  otherwise  be  overlooked. 

Treatment. — The  traumatic  reaction  is  often  severe  during  the 
first  few  days  or  week  in  fractures  of  this  bone  and  during  this 
time  it  is  advisable  to  treat  the  leg  in  the  pillow  splint,  in  the  ele- 
vated position  and  with  the  intermittent  use  of  the  ice  cap.  When 
the  swelling  has  subsided  the  foot  and  ankle  may  be  fixed  in  a 
short  plaster  stirrup  after  the  parts  have  been  properly  covered 
with  sheet  cotton  to  provide  the  necessary  padding.  The  best 
reduction  is  usually  had  in  a  position  of  slight  plantar  flexion, 
which  position  is  preferable  in  most  cases  to  the  academic  "right 


696  FRACTURES   AND    DISLOCATIONS 

angle,"  so  insistently  and  nselessly  deniandod  in  most  text-books. 
If  tile  eondition  is  aceonipanied  hy  otlicr  fi-aelui-es  in  the  foot  a 
more  complete  fixation  may  Ijc  rtMniii'cd.  and  is  liad  li\'  means  of  a 
short  iH)sterior  plaster  splint.  This  splint  is  applieil  before  tiie 
stirrni>  and  extends  down  tlie  leg  and  nndei-  the  foot  to  a  point 
just  beyond  llic  loes.  Il  is  the  same  as  usvil  in  fractures  of  the 
metatarsals. 

In  disloeations  of  the  astragalus  i-educlion  sliould  be  effected  at 
the  earliest  possible  moment,  unless  the  condition  is  compound. 
The  necessary  manipulations  will  depend  entirely  upon  the  posi- 
tion occupied  by  the  displaced  bone.  The  oljject  is  to  return  the 
trochlear  surface  of  the  astragalus  to  its  proper  relation  in  the 
moitise  formed  by  the  tibia  and  fibula.  This  may  be  a  difficult 
matter  especially  if  rotation  of  the  bone  has  occurred.  The  fact 
that  no  tendons  are  inserted  into  the  astragalus  increases  the  diffi- 
culty of  reduction. 

In  forward  displacements  of  the  bone,  direct  backward  pressure 
on  the  prominent  trochlear  surface  will  usually  effect  reduction. 
Plantar  flexion  before  the  bone  is  "started,"  and  dorsal  flexion  in 
the  latter  part  of  the  manipulation  may  aid  materially  in  reduction. 

In  the  forward  and  outward  type  of  luxation  similar  maneuvers 
are  employed.  The  common  outward  rotation  of  the  bone  is  often 
difficult  to  correct,  and  until  it  is,  it  will  usually  be  impossible  to 
effect  reposition.  Strong  traction  on  the  foot  and  sometimes  an 
accentuation  of  the  inversion  will  render  the  direct  pressure  more 
efficient. 

In  inward  and  forward  luxations  the  opposite  manipulations 
are  necessary  to  return  the  bone  to  its  normal  position. 

In  backward  luxations  with  the  usual  fracture  of  the  neck,  strong 
traction  with  direct  forward  pressure  on  either  side  of  the  ankle 
in  front  of  the  tendo  Achillis,  will  usually  be  sufficient  to  accom- 
plish reduction.  Plantar  flexion  of  the  foot  while  traction  is  being 
made,  will  increase  the  distance  between  the  calcaneum  and  the 
tibio-fibular  mortise  posteriorly  and  may  thus  facilitate  reduction. 
If  I'eduction  cannot  be  accomplished  by  manipulation,  open  incision 
under  proper  surgical  surroundings  should  be  resorted  to  at  once. 
This  is  particularly  true  of  any  of  the  anterior  luxations,  since  the 
pressure  exerted  by  the  displaced  bone  may  produce  sloughing  of 
the  integument  and  render  the  condition  compound.  The  fact 
that  the  trochlear  surface  is  slightly  broader  anteriorly  accounts 


FRACTURES   AND   DISLOCATIONS   OF   ASTRAGALUS  697 

for  the  frequency  of  complicating  fractures  of  the  inalk;oli  in  back- 
ward luxations.  When  either  of  the  malleoli  are  broken  they  de- 
serve special  consideration  in  the  treatment  (see  "Pott's  Frac- 
ture," page  668,  and  "Dislocations  of  the  Ankle,"  page  689.  The 
treatment  of  lateral  dislocations  with  fracture  of  the  malleoli  is 
similar  to  that  already  given  for  lateral  luxations  of  the  ankle. 
When  either  fracture  or  luxation  of  the  astragalus  is  compound, 
immediate  operative  intervention  is  demanded. 

Operative  Treatment. — Operation  is  seldom  indicated  in  the 
treatment  of  simple,  uncomplicated  fractures  of  the  astragalus. 
It  is  called  for  in  compound  cases  and  in  instances  in  which  lux- 
ations of  the  bone  cannot  l)e  innnediately  corrected  by  manipula- 
tion. In  compound  cases  no  attempt  at  reduction  should  be  made 
until  the  patient  is  in  the  operating  room.  The  skin  should  be 
painted  with  a  five  percent  tincture  of  iodine,  lacerated  and  de- 
vitalized tissue  should  be  trimmed  away  from  the  margin  of  the 
wound  and  the  cavity  irrigated  with  a  few  gallons  of  sterile  salt 
solution.     The  surgeon  then  determines  what  the  individual  needs 


Fig.    772. — Deformed    astragalus    removed    to    restore    function.      Old    fracture    with 
union  in  deformity. 

of  the  case  may  be.  Fractures  usually  require  nothing  in  the  way 
of  reduction,  and  internal  fixation  of  the  fragments  is  not  feasible. 

In  luxations  the  bone  is  to  be  returned  to  its  normal  position  by 
direct  manipulation  while  traction,  flexion,  extension  or  other 
needed  maneuvers  of  the  foot  are  carried  out.  Care  should  be 
exercised  to  avoid  injury  to  the  articular  surfaces  while  grasping 
the  bone  with  forceps.  The  best  place  to  grasp  the  astragalus  and 
one  in  which  the  teeth  of  the  forceps  will  do  no  damage,  is  at  the 
neck. 

The  wound  is  then  closed  wdth  interrupted  sutures.  If  diffi- 
culty is  experienced  in  bringing  the  edges  of  the  wound  together, 
after  the  devitalized  tissue  has  been  removed,  it  may  be  necessary 
to  perform  some  plastic,  skin-sliding  operation.     It  is  imperative 


698  FRACTURES   AND    DISLOCATIONS 

that  the  wound  be  closed  at  tliis  time,  evtMi  at  the  expense  of  leaving 
some  adjoining  area  deniulcd.  It'  .suppuration  occurs  in  spite  of 
this  treatment  (and  it  rarely  docs)   drainage  will   lie  necessary. 

Excision  of  the  bone  in  difficult  cases  was  the  usual  treatment  a 
few  years  ago  but  at  the  present  time  there  seems  to  be  no  excuse 
for  this  procedure,  except  in  the  most  extreme  cases.  In  old  un- 
reduced luxations,  and  in  recent  cases  in  which  necrosis  develops 
in  the  astragalus  it  may  be  necessary  to  excise  the  bone,  either  en- 
tirely or  in  part.  In  instances  in  which  ankylosis  of  the  tibio- 
tarsal  articulation  follows  suppuration  surprisingly  good  function 
may  be  restored  by  a  s[)ontaneous  increase  in  the  range  of  motion 
in  the  medio-tarsal  articulation. 

After-Treatment. — In  fractures  of  the  astragalus  due  time  should 
be  allowed  for  proper  union  of  the  fragments.  It  should  be  re- 
membered in  this  respect  that  the  strain  entailed  in  ordinary  walk- 
ing is  considerable,  and  unless  the  callus  is  well  ossified  and  solid, 
deformity  may  follow.  The  foot  should  be  protected  from  weight 
bearing  until  two  months  or  more  have  elapsed  from  the  time  of 
the  injurj^  and  even  then  function  should  be  only  gradually  re- 
sumed. IMassage  and  early  passive  motion,  however,  are  essential 
in  preventing  joint  adhesions,  and  if  properly  employed,  subject 
the  parts  to  very  slight  strain. 

The  resumi^tion  of  function  may  be  begun  at  the  end  of  four 
or  five  weeks  in  simple  luxations.  Complicating  fractures  of  ad- 
joining bones  modify  the  after-treatment  according  to  the  nature 
of  the  lesion. 

Prognosis. — In  simple  luxations  of  the  astragalus,  with  proper 
and  prompt  reduction,  we  may  look  for  practically  complete  res- 
toration of  function.  The  outlook  in  fractures  depends  on  the 
severity  of  the  lesion  and  is  not  generally  as  favorable  as  is  the 
case  in  simple  dislocations.  Recovery  is  slower  and  ultimately 
some  restriction  in  motion  may  exist.  Simple  transverse  fracture 
of  the  neck  is  usually  followed  by  better  results  than  is  usual  with 
fractures  of  the  body. 

In  instances  in  which  luxations  have  been  allowed  to  go  un- 
treated the  loss  of  function  and  deformity  are  usually  pronounced. 
Surprisingly  good  function,  however,  frequently  follows  complete 
removal  of  the  bone. 


CHAPTER  L. 

SUBASTRAGALAR  LUXATIONS. 

Surgical  Anatomy. — The  astragalus  rests  upon,  and  articulates 
with,  the  calcaneum  by  two  facets  which  are  divided  by  a  deep 
groove  for  the  attachment  of  the  heavy  interosseous  ligament. 
The  calcaneum  and  astragalus  are  directly  bound  together  by  the 
internal,  external  and  posterior  calcaneo-astragaloid  ligaments  and 
by  the  interosseous  ligament.  Both  the  internal  and  external 
lateral  ligaments  of  the  ankle-joint  are  attached  below  to  the  cal- 
caneum as  well  as  the  astragalus,  and  in  subastragalar  luxations 
either  of  the  malleoli  may  be  broken  by  the  direct  pull  of  these 
ligaments.  The  relatively  low  position  of  the  external  malleolus 
exposes  it  to  fracture  by  direct  pressure  of  the  calcaneum  when  the 
luxation  is  outward.  The  only  ligament  passing  between  the  as- 
tragalus and  navicular  is  the  superior  astragalo-navicular  which  is 
thin  and  weak.  The  place  of  the  lower  ligament  is  taken  by  the 
calcaneo-navicular  ligament.  This  ligament,  by  binding  the  cal- 
caneum to  the  navicular,  maintains  the  head  of  the  astragalus  in 
apposition  with  the  navicular. 

In  subastragalar  dislocations  the  calcaneum  may  be  displaced 
inward,  outward,  backward  or  forward.  The  astragalus  remains 
in  position  in  the  tibio-fibular  mortise  while  the  bones  of  the  tarsus 
below  it  are  displaced  as  a  whole.  The  most  common  luxation  is 
lateral,  oblique,  incomplete  and  often  compound.  The  displace- 
ment is  usually  more  complete  in  the  posterior  subastragalar  joint 
than  in  the  anterior.  The  head  of  the  astragalus  is,  as  a  rule,  com- 
pletely separated  from  the  navicular.  There  is  often  slight  back- 
ward displacement  accompanying  either  the  inward  or  outward 
luxation.  Forward  luxations  are  extremely  rare,  resembling  in 
this  respect  forward  dislocations  of  the  ankle-joint.  The  articula- 
tion between  the  head  of  the  astragalus  and  the  navicular  is  almost 
invariably  broken  up  in  subastragalar  luxations  regardless  of  the 
direction  in  which  the  foot  is  displaced. 

The  usual  subastragalar  luxation  is  the  result  of  forcible  inver- 
sion or  eversion  of  the  foot  and  not  infrequently  occurs  in  falls 

699 


TOO 


FRACTl'RKS    A.\|)    DISLOCATIONS 


Oil  the  foot.  This  type  of  violence  is  imicli  more  likely  to  produce 
fracture-luxations  of  the  ankle  Ihan  dislocations  of  the  suhastraga- 
lai'  articulation.  P'l'aclui'c  of  the  neck  of  IIk^  astragalus  is  a  coin- 
plicalion  wliidi  lias  been  reeordt'd  in  a  uuinber  of  eases. 

Symptoms. — In  outward  luxations  the  sole  of  the  foot  looks  down- 
ward and  outward  and  llic  whole   fool   is  dispjacfd   lalcrally.      'riie 


Figs.  773  and  774. — Case  of  backward  dislocation  of  the  calcaneum  and  scaphoid  on 
the  astragalus.  (Backward  subastragalar  luxation.)  The  calcaneo-astragalar  .loint  has 
been  dislocated  and  the  articulation  between  the  astragalus  and  navicular  has  been 
entirely  broken  up.  The  head  of  the  astragalus  is  seen  presenting  in  the  wound  with 
the  tendon  of  the  tibialis  anticus  lying  internal  to  it.  Result  of  falling  down  an  elevator 
shaft.  The  foot  below  the  astragalus  is  displaced  backward.  Note  the  prominence  of 
the  heel. 


inner  malleolus  is  abnormally  prominent  and  the  head  of  the  as- 
tragalus may  be  palpated.  The  malleoli  are  in  normal  relation 
with  each  other  and  with  the  astragalus,  which  is  not  displaced 
with  the  foot.     The  external  malleolus  is  less  prominent  than  nor- 


SUBASTRAGALAR   LUXATIONS  701 

mal.  If  backward  displacement  of  the  foot  exists,  as  well  as  lateral, 
there  will  be  an  undue  prominence  of  the  heel  and  a  corresponding 
shortening  of  the  dorsum  of  the  foot. 

In  inward  luxations  the  reverse  deformity  is  seen.  The  sole  of 
the  foot  looks  downward  and  inward.  The  inner  border  is  raised 
and  more  concave  than  normal.  The  external  malleolus  is  unduly 
prominent.  The  head  of  the  astragalus  may  be  palpated  and  the 
scaphoid  may  be  felt  near  the  inner  malleolus.  The  whole  foot  is 
displaced  inward.  Antero-posterior  luxations  resemble  disloca- 
tions of  the  ankle  in  the  same  plane.  The  fact  that  the  astragalus, 
however,  remains  in  its  normal  relation  with  the  bones  of  the  leg 
causes  the  deformity  to  be  at  an  obviously  lower  level  than  that 
seen  in  dislocations  of  the  ankle. 

In  posterior  luxations  the  dorsum  of  the  foot  is  shortened  and 
the  heel  abnormally  prominent.  The  head  of  the  astragalus  pro- 
jects into  the  bend  of  the  ankle  and  may  be  readily  recognized  in 
this  position.  The  condition  may  be  compound  as  shown  in  Figs. 
773  and  774. 

Anterior  luxations  are  extremely  rare.  The  heel  is  shortened 
and  the  dorsum  of  the  foot  lengthened.  Palpation  reveals  the 
astragalus  in  its  tibio-fibular  mortise. 

Diagnosis. — The  diagnosis  of  these  luxations  is  based  on  the 
characteristic  deformities  just  described.  If  the  swelling  is  in- 
tense it  may  be  difficult  to  recognize  the  exact  nature  of  the  de- 
formity. An  X-ray  is  of  the  greatest  value  in  ascertaining  the 
details  of  the  injury. 

Treatment. — There  is  seldom  much  difficulty  in  reducing  the 
deformity.  In  the  lateral  luxations  the  surgeon  secures  a  firm 
grasp  of  the  heel  with  one  hand  and  the  dorsum  of  the  foot  with 
the  other,  and  by  strong  traction  the  foot  is  brought  back  into 
position.  Counter-traction  will  usually  be  needed  and  should  be 
made  by  an  assistant,  above  the  ankle.  In  backward  luxations  for- 
ward traction  should  be  exerted  on  the  heel  while  the  leg  is  fixed. 
The  reverse  manipulation  is  performed  to  correct  anterior  lux- 
ations. The  parts  should  be  fixed  in  a  plaster  cast  extending  from 
the  middle  of  the  leg  to  the  toes  and  cut  open  before  the  plaster 
has  dried. 

Operative  Treatment. — If  reduction  cannot  be  performed  by 
manipulation,  open  incision  with  direct  reposition  of  the  displaced 
bones  should  be  performed. 


702  FRACTURES    AX[i    niSLOC'ATIONS 

After-Treatment.  Finn  union  of  llic  liR'rratrd  ligaments  will  be 
present  at  the  end  of  two  and  a  linlt'  to  three  weeks.  Passive  motion 
should  be  begun  at  the  end  of  ten  days  hut  the  patient  should  not 
be  allowed  to  bear  his  weight  on  the  foot  inside  of  three  weeks 
from  the  time  of  the  accident. 

Prognosis. — The  loss  of  function  following  this  accident  is  very 
trivial  it'  proi>er  reduction  of  the  displacement  has  been  accom- 
plished following  the  injury.  Like  dislocations  in  other  joints, 
the  too  cjirlx-  use  of  the  parts  is  likely  to  be  followed  by  recurrence 
of  the  luxation  wliidi  nun*  even  become  habitual. 


CHAPTER  LI. 

FRACTURES  AND  DISLOCATIONS  OF  THE 
CALCANEUM. 

Surgical  Anatomy. — Fracture  of  the  os  calcis  is  a  fairly  common 
accident  but  isolated  luxations  of  this  bone  are  extremely  rare. 
The  internal  structure  of  the  bone  is  cancellated  while  the  surface 
is  composed,  for  the  most  part,  of  a  thin  layer  of  compact  tissue. 
The  surface  layer  is  heavier  on  the  external,  lateral  surface  of  the 
bone  than  elsewhere.  The  os  calcis  articulates  above  with  the 
astragalus  by  two  facets,  which  are  divided  by  a  deep  groove  for 
the  attachment  of  the  heavy  interosseous  ligament  binding  these 
two  bones  together.  The  anterior  extremity  of  the  calcaneum  ar- 
ticulates with  the  cuboid  which  in  turn  supports  the  fourth  and 
fifth  metatarsal  bones.  The  os  calcis  is  connected  by  ligaments 
with  the  astragalus,  cuboid,  navicular  and  to  the  second,  third  and 
fourth  metatarsal  bones.  A  number  of  the  intrinsic  muscles  of 
the  foot,  as  well  as  one  of  the  secondary  insertions  of  the  tibialis 
posticus,  are  attached  to  the  calcaneum  but  the  muscles  of  surgical 
importance  finding  attachment  on  this  bone  are  the  gastrocnemius 
and  soleus.  These  muscles  are  inserted  through  their  common 
tendon,  the  tendo  Achillis,  into  the  lower  part  of  the  posterior 
surface  of  the  bone.  The  fact  that  this  tendon  is  inserted  into  the 
lower  and  not  the  upper  part  of  the  posterior  surface  accounts  for 
the  peculiar  displacement  of  the  fragment  when  fracture  results 
from  muscular  action. 

A  small  anomalous  bone  (the  trigonum)  is  sometimes  present 
just  behind  the  posterior  subastragalar  joint,  and  if  one  is  not 
familiar  with  its  appearance  it  may  be  mistaken  for  a  fracture,  in 
interpreting  an  X-ray  plate  (see  Fig.  776).  The  os  calcis  is  ossi- 
fied by  two  centers :  one  for  the  main  portion  of  the  bone,  and  the 
other  for  the  epiphysis.  That  for  the  body  makes  its  appearance 
during  the  sixth  foetal  month.  The  center  for  the  epiphysis  is 
first  seen  during  the  tenth  year  and  joins  the  body  of  the  bone 
soon  after  puberty.  It  should  not  be  mistaken,  during  this  period, 
for  a  fracture  of  the  posterior  portion  of  the  bone. 

703 


704 


FRACTURES    AND    DISLOCATIONS 


I'^i-actuTo  of  tli(^  cnlcancnin  )iia\'  I'i'siilt  rroiii  falls  on  the  foot, 
lioiii  iiiusciilai-  i-oiiti'at'liou  and  t'roiii  fofcililc  twisting  of  the  foot. 
The  fracture  may  be  transverse,  or  longitudinal,  and  not  infre- 
quently extensive  eoniniinution  of  the  lione  exists.  Anj'  portion 
of  tlie  bone  may  be  broken  and  tlie  posterior  part  is  often  displaced 


Fig.    776. 


Fig.   775. — Fracture  of  calcaneum. 

Fig.    776. — Anomalous  bone  present    (the  trigonum)    wiiich  mi.?ht   readily  be  mistaken 
for   a   fracture. 


Fig.   777. — Fracture  of  calcaneum. 


Fig.    778. — Fracture  of  calcanenm. 


outward  as  well  as  upward.  The  usual  break  is  produced  by  a  fall 
from  a  height  in  which  the  patient  lands  on  the  foot.  There  is 
usually  more  or  less  comminution  and  crushing  of  the  bone  below 
and  behind  the  astragalus,  and  not  infrequently  the  line  of  frac- 
ture  enters   the   posterior   subastragalar   articulation.     This   com- 


FRACTURES    AND   DISLOCATIONS    OF    CALCANEUM  705 

miniition  results  in  an  increase  in  th(!  width  of  the  bone.  'I'vvisting 
of  the  foot  and  falls  on  the  foot  while  inverted  are  said  to  be  |)ro- 
ductive  of  fractures  of  the  sustentaculum  tali. 

When  fracture  results  from  a  twist  of  the  foot  the  line  of  the 
break  is  more  clean  cut  and  the  deformity  is,  as  a  rule,  slight. 

When  fracture  occurs  as  the  result  of  overaction  of  the  calf 
muscles  the  line  of  the  break  and  the  deformity  are  usually  charac- 
teristic. A  small  fragment  is  detached  from  the  posterior  portion 
of  the  bone  and  displaced  upward  by  the  pull  of  the  tendo  Achillis. 
The  upper  end  of  the  fragment  commonly  remains  in  contact  with 
the  body  of  the  calcaneum  while  the  lower  end  describes  an  arc 
upward  and  backward. 

Isolated  dislocation  of  the  calcaneum  is  an  extremely  rare  con- 
dition and  is  essentially  the  same  as  an  incomplete  subastragalar 
luxation.  The  bone  is  torn  away  from  its  attachments  to  the 
astragalus  and  cuboid  and  is  most  often  displaced  outward.  The 
symptoms  and  treatment  are  practically  the  same  as  that  given 
under  the  heading  of  "Subastragalar  Luxations,"  page  700. 

Symptoms. — The  patient  complains  of  pain  in  the  region  of  the 
injury  particularly  when  an  attempt  is  made  to  stand  on  the  foot. 
If  weight  is  placed  on  the  heel  the  direct  pressure  produces  suf- 
fering. If  the  weight  is  placed  on  the  ball  of  the  foot  the  action 
of  the  calf  muscles  will  pull  upward  on  the  calcaneum  and  the  at- 
tempt will  be  equally  painful.  Swelling  usually  develops  promptly 
following  the  accident  and  is  noted  on  either  side  of  the  foot  below 
the  ankle,  especially  to  the  inner  side.  The  foot  often  gives  the 
appearance  of  flat-foot.  The  heel  is  broadened,  elevated  and  often 
displaced  outward.  If  there  has  been  much  comminution  of  the 
calcaneum  its  width  will  be  increased  and  the  outward  displace- 
ment of  the  external  wall  may  be  recognized  by  palpation  below 
the  external  malleolus.  Flexion  and  extension  of  the  ankle  will 
be  free  but  lateral  motions  of  the  foot  involving  the  tarsal  joints 
will  be  restricted,  especially  if  the  fracture  has  entered  the  pos- 
terior subastragalar  articulation  as  it  so  frequently  does.  Crepitus 
can  usually  be  elicited  by  manipulating  the  heel  but  it  is  never 
sharp  and  pronounced.  This  is  explained  by  the  small  amount  of 
compact  tissue  in  the  calcaneum. 

In  luxations  of  the  calcaneum  the  heel  is  displaced  as  a  whole, 
either  inward  or  outward.  There  is  abnormal  mobility,  no  crepitus 
and  no  upward  displacement  as  in  fracture. 


706  FR.VCTrRES    AND    DISLOCATIONS 

Diagnosis. — The  diagnosis  is  based  on  the  preceding  syraptons 
but  should  be  confirmed  by  the  X-ray.  This  renders  the  diagnosis 
certain,  informs  the  surgeon  of  the  exact  nature  of  the  fracture 
and  discloses  complicating  injuries  of  adjoining  bones  when  they 
occur.  Notwithstanding  the  great  differences  in  the  symptoms  of 
the  two  conditions,  fracture  of  the  os  ealcis  has  been  mistaken  for 
Pott's  fracture,  in  a  number  of  instances  of  wliidi  the  author 
knows.  The  normal  positions  and  relations  of  the  malleoli  and 
the  position  of  the  astragalus  in  the  tibio-fibulai-  moitise  should 
serve  to  diflferentiate  this  condition  from  lesions  higher  up.  Im- 
pacted fracture  of  the  os  ealcis  may  be  quite  difficult  to  recog- 
nize without  the  aid  of  the  X-ray,  If  a  stereoscopic  Riintgenogram 
is  made  it  will  aid  the  surgeon  materially  in  appreciating  the  de- 
formity. There  is  considerable  variation  in  the  normal  contours 
of  different  calcanea  and  it  is  therefore  advisable  to  have  a  plate 
made  of  the  opposite  foot  for  the  sake  of  comparison. 

Treatment, — The  treatment  of  fracture  of  the  os  ealcis  is  to 
imnio])ilize  the  foot  in  a  position  which  will  correct  the  deformity. 
Complete  plantar  flexion  of  the  foot  relieves,  to  a  large  extent,  the 
displacing  pull  of  the  calf  muscles  inserted  through  the  tendo 
Achillis.  Fixation  is  usually  best  accomplished  by  means  of  a 
short,  well  padded,  plaster  stirrup.  While  the  plaster  is  setting 
the  surgeon  should  hold  the  bone  in  reduction ;  this  can  be  done  In- 
grasping  the  heel  and  pulling  it  down\vard  and  slightly  inward. 
The  stirrup  is  moulded  tightly  about  the  tendo  Achillis  at  the  back 
of  the  ankle  and  when  the  plaster  is  firmly  set  prevents  upward 
displacement  of  the  posterior  end  of  the  calcaneum.  The  portion 
of  the  stirrup  passing  under  the  foot  should  be  so  moulded  that  it 
supports  the  arch  of  the  foot.  Reduction  and  fixation  can,  as  a 
rule,  be  satisfactorily  accomplished  in  this  way.  If,  however,  the 
pull  of  the  calf  muscles  proves  greater  than  can  be  overcome  by 
this  dressing  a  tenotomy  of  the  tendo  Achillis  may  be  required  to 
prevent  recurrence  of  deformity.  When  considerable  broadening 
of  the  calcaneum  exists  as  a  result  of  crushing  of  the  bone  it  may 
be  necessary  to  force  the  sides  of  the  bone  toward  each  other  by 
lateral  pressure  beneath  the  malleoli.  If  the  surgeon  has  a  power- 
ful grip  this  ma.y  be  accomplished  manually.  An  anesthetic  should 
be  employed  to  correct  the  deformity  and  apply  the  plaster  stirrup. 

Operative  Treatment. — Aside  from  tenotomy  (which  is  rarely 
needed)  operation  is  called  for  in  compound  cases,  and  in  instances 


FRACTURES    AND   DISLOCATIONS   OP    CALCANEUM  707 

in  which  the  fragment  has  been  detached  and  displaced  upward  by 
the  pull  of  the  calf  muscles.  Compound  fracture  of  the  calcaneuin 
is  to  be  treated  according  to  the  principles  laid  down  on  page  789. 
In  severe  crushing  injuries,  with  destruction  of  the  soft  tissues 
covering  the  calcaneum,  plastic  operations  and  skin  grafting  may 
be  called  for  to  cover  the  bone.  Necrosis  may  require  sequestrot- 
omy. 

If  a  fragment,  displaced  by  the  tendo  Achillis,  is  not  readily 
held  in  position  by  pads  (and  it  seldom  is),  operation  with  direct 
fixation  of  the  fragment  is  indicated.  Nailing  of  the  fragment  is 
not  advisable  because  of  the  soft  cancellous  tissue  in  which  the 
nail  must  be  placed.  A  small  mattress  suture,  preferably  of  silver 
wire,  is  probably  the  best  method  of  securing  the  fragment  in 
position. 

Outward  displacement  of  the  external  surface  of  the  bone  may 
give  rise  to  an  extremely  tender  point  below  the  outer  malleolus, 
when  the  patient  resumes  the  use  of  the  foot.  This  may  call  for 
removal,  by  chiseling,  of  the  portion  of  bone  impinging  against  the 
inner  side  of  the  malleolus.  The  formation  of  excessive  callus  in 
this  region  may  produce  the  same  symptoms  and  calls  for  similar 
treatment.  A  fragment  or  spicule  of  bone  projecting  into  the  sole 
may  render  walking  excessively  painful  and  calls  for  removal  of 
the  offending  portion  of  bone  after  the  diagnosis  has  been  con- 
firmed by  the  X-ray.  Union  with  extreme  deformity  may  be  fol- 
lowed by  such  pronounced  disturbances  in  function  that  operation 
is  demanded  for  the  relief  of  the  condition.  A  transverse  oste- 
otomy of  the  calcaneum  just  behind  its  articulation  with  the 
astragalus,  with  correction  of  the  deformity,  should  be  done. 

Operative  treatment  is  not  indicated  in  uncomplicated  luxations 
of  the  calcaneum. 

After-Treatment. — Union  takes  place  rapidly  in  the  calcaneum 
but  it  should  be  remembered  that  the  strain  imposed  on  the  bone 
in  walking  is  great,  and  unless  the  callus  is  solidly  ossified  sec- 
ondary deformity  may  develop. 

By  means  of  a  properly  applied  plaster  stirimp  the  foot  is  im- 
mobilized for  a  period  of  from  four  to  six  weeks.  Passive  motion 
and  gentle  massage  should  be  instituted  at  the  end  of  two  weeks. 
No  weight  should  be  borne  on  the  injured  foot  within  two  or  two 
and  a  half  months  and  the  resumption  of  function  should  be  grad- 
ual.    If  the   fracture  has  been  a  severe   one   this   time   may   be 


708  FRACrrKES    AXU    niSLOCATlONS 

increased.  Secondary  upward  displacenieiit  of  tlie  lieel  and  the 
development  of  static  tiat-foot  arc  the  i-csnlts  of  too  early  use  of 
the  foot  in  vvalking.  Free  active  and  [)assi\c  motion  are  of  advan- 
tajre  in  the  treatment  of  the  case  many  weeks  before  it  is  safe  to 
allow  the  fidl  weijjlit  to  he  borne  on  the  injured  mend)ei'.  In  cases 
in  wliicJ!  the  t-alcaneinn  has  united  in  deformitx'  a  pad  may  be 
worn  in  the  shoe  beneath  the  heel  and  will  often  alt'ord  ^reat  com- 
fort. In  instances  in  which  ti-anmatic  tiat-foot  occui-s  arches  may 
be  worn  within  the  shoe  to  suppoi't  the  inner  side  of  the  foot. 
These  measures,  however,  are  ])Oor  substitutes  for  union  with  the 
fragments  in  proper  position,  and  will  seldom  be  needed  if  the 
deformity  has  been  properly  coi'i-cctcd  and  held  in  rcd\ic1ion  fol- 
lowing- the  injur.w 

Prognosis. — With  proper  treatment  uncomplicated  fracture  of 
the  OS  calcis  should  be  followed  by  fair  restoration  of  function. 
The  most  important  secpielffi  are:  tiat-foot,  restriction  of  motion  in 
the  subastragalar  articulation,  metatarsalgia,  pain  beneath  the 
outer  malleolus,  and  painful  heel  caused  by  a  projecting  fragment. 
The  more  perfectly  the  deformity  is  corrected  following  the  acci- 
dent the  less  the  probability  of  these  annoying  and  disabling 
sequelae.  Occasionally,  however,  a  case  is  seen  in  which  the  most 
perfect  reduction  and  painstaking  after-treatment  have  been  car- 
ried out  and  yet  there  is  considerable  disturbance  in  function  as  a 
result  of  one  or  more  of  these  conditions.  Flat-foot  may  be  treated 
by  means  of  arches  within  the  shoe  or  if  severe  an  osteotomy  of  the 
caleaneura  may  be  performed  and  is  usually  followed  by  pro- 
nounced improvement.  The  motion  in  the  subastragalar  articu- 
lation may  be  increased  by  forcible  passive  motion  under  anesthesia, 
which  may  be  repeated  many  times  if  necessary.  IMetatarsalgia  is 
a  result  of  flat-foot  and  wall  pass  off  wdth  removal  of  the  cause. 
Pain  beneath  the  outer  malleolus  is  relieved  by  removing  the  por- 
tion of  bone  causing  the  pressure.  Removal  of  spurs  on  the  under 
surface  of  the  calcaneum  will  be  followed  by  prompt  and  complete 
relief.  Considering  the  causes  of  disturbed  function  and  the  pos- 
sibility of  relief  the  prognosis  is  not  so  bad  provided  the  patient 
is  willing  to  submit  to  the  necessary  corrective  measures. 


CHAPTER  LII. 

MEDIO-TARSAL  LUXATIONS. 

Surgical  Anatomy. — Luxations  sometimes,  though  rarely,  occur 
at  the  medio-tarsal  joint,  the  anterior  portion  of  the  foot  being 
more  or  less  completely  displaced  from  the  posterior.  The  bones 
entering  into  the  articulation  are  proximally  the  astragalus  and 
ealcaneum,  and  distally  the  navicular  and  cuboid.  The  ligaments 
connecting  these  bones  are  very  powerful  and  tlie  articulation  is 
seldom  broken  up  except  in  crushes  of  the  foot.  The  inner  portion 
of  this  joint  is  a  part  of  the  anterior  subastragalar  articulation. 
The  outer  part  of  the  joint  (the  calcaneo-cuboid)  has  a  separate 
synovial  cavity.  The  pliability  of  the  foot  depends  mainly  on  the 
subastragalar  and  medio-tarsal  articulations.  Luxations  of  the 
medio-tarsal  articulation  have  been  so  confounded  with  subastraga- 
lar luxations  that  only  a  few  of  the  reported  cases  can  be  con- 
sidered sufficiently  dependable  to  deserve  consideration.  Disloca- 
tion, uncomplicated  by  fracture,  rarely  if  ever  occurs.  The 
displacement  may  be  inward,  downward  or  outward.  Upward 
luxation  of  the  bones  probably  occurs  only  as  a  secondary  element 
in  outward  luxations.  In  most  of  the  cases  the  deformity  has 
resembled  that  of  an  inward  subastragalar  luxation.  The  anterior 
portion  of  the  foot  is  shortened,  the  inner  border  raised  and  more 
concave  than  normal.  The  calcaneum  is  not  deviated  as  in  sub- 
astragalar luxations.  Crepitus  is  usually  present  as  a  result  of 
complicating  fracture.  The  anterior  portion  of  the  foot  is  abnor- 
mally mobile.  The  anterior  ends  of  the  calcaneum  and  astragalus 
produce  a  distinct  ridge  on  the  dorsum  of  the  foot. 

In  outward  luxations  the  foot  is  pronated  and  the  scaphoid  and 
cuboid  slightly  raised. 

Treatment, — The  treatment  consists  in  reducing  the  luxation  and 
immobilizing  the  parts  sufficiently  long  to  allow  healing  of  the  liga- 
ments. Reduction  should  be  accomplished  by  open  incision  if  non- 
operative  measur(;s  fail.  The  treatment,  operative  treatment,  after- 
treatment  and  prognosis  are  similar  to  those  given  under  ''Sub- 
astragalar Luxations,"  page  699. 

709 


CHAPTER  LIII. 

FRACTURES  AND  LUXATIONS   OF   THE   CUBOID, 
SCAPHOID  AND   CUNEIFORMS. 

Surgical  Anatomy. — The  cuboid  articulates  with  the  calcaneum 
posteriorly  and  to  the  iuner  side  with  the  external  cuneiform.  It 
supports  the  outei-  two  metatarsals  and  is  sei'iii-(4\-  ludd  in  position 
by  heavy  ligaments  connecting  it  with  the  adjoining  hones.  Frac- 
ture of  the  cuboid  is  not  an  uncommon  lesion,  especially  in  crushing 
injuries  of  the  foot,  but  isolated  luxation  of  this  bone  is  hardly 
more  than  a  surgical  anomaly.  Fracture  usually  results  from  di- 
rect violence  to  the  dorsum  of  the  foot  and  since  the  bone  is  prac- 
tically subcutaneous  the  condition  is  often  compound.  The  three 
cuneiforms  are  firmly  bound  together  and  to  the  surrounding  bones 
by  heavy  ligaments  and  like  the  cuboid  are  rarely  luxated.  Frac- 
ture of  these  bones  is  usually  the  result  of  direct  violence.  Cases 
of  partial  displacements  of  the  navicular  and  cuneiforms  have  been 
reported  but  the  mechanism  is  not  clear.  It  should  be  remembered 
that  the  tibialis  anticus  and  tibialis  posticus,  two  powerful  mus- 
cles, find  their  main  insertions  on  the  cuneiforms  and  navicular. 

The  cuboid,  navicular  and  cuneiforms  are  all  composed  of  can- 
cellous tissue  internally,  while  the  surface  is  made  up  of  a  thin 
layer  of  compact  bone.  They  are  firmly  bound  together  by  heavy 
ligaments  and  are  usually  fractured  by  direct  violence  to  the 
dorsum  of  the  foot.  The  soft  tissues  covering  the  dorsum  of  the 
foot  are  scant  and  the  lesion  is  often  compound.  When  the  frac- 
ture is  not  compound  from  the  first,  it  often  becomes  so  later,  as  a 
result  of  sloughing  of  the  integument  on  the  dorsum  of  the  foot. 

A  crushing  of  the  tarsal  or  metatarsal  bones  is  an  accident  not 
uncommonly  seen  among  railroad  employees.  The  foot  is  caught 
beneath  the  wheels  of  a  car  and  more  or  less  severely  crushed.  If 
the  train  is  moving  with  much  speed  the  foot  is  crushed  and  ampu- 
tated. If  the  rate  at  which  the  train  is  moving  is  slow  the  foot 
may  be  pushed  aside  and  only  partially  crushed. 

Treatment. — In  fractures  of  the  anterior  bones  of  the  tarsus, 

710 


FRACTURES    AND    LUXATIONS    OF    (UfBOID    AND    SCAPHOID 


711 


whatever  deformity  is  present  should  be  corrected  and  the  foot 
immobilized  on  a  plaster  sole  as  shown  in  Fig.  787.  This  splint 
should  extend  from  the  middle  of  the  leg  to  a  point  beyond  the 
toes.  A  plaster  cast  should  not  be  used  since  secondary  sloughing 
is  not  uncommon  and  the  skin  dn  the  dorsum  of  the  foot  should  be 


Fig.    780. 

Figs.  779  and  780. — Crushing  injuries  of  feet  sustained  beneath  car-wheels.  Crash- 
ing disarticulation  through  tarso-metatarsal  joint.  In  the  upper  plate  (Fig.  779)  the 
lower  portion  of  the  foot  is  not  completely  severed  though  the  tissues  are  so  thoroughly 
mangled  that  the  circulation  is  destroyed  and  amputation  is  necessary.  In  the  lower 
plate  (Fig.  780)  the  lower  portion  of  the  foot  was  completely  severed  at  the  time  of 
the   accident. 


open  to  inspection  during  the  after-treatment.  The  damage  to  the 
soft  tissues  is  often  more  important  than  the  fracture.  If  slough- 
ing occurs  the  parts  should  be  frequently  dressed  and  the  sloughing 
area  kept  as  aseptic  as  possible.  Granulations  should  be  cultivated 
and  stimulated  by  balsam  of  Peru  and  in  removing  the  dressings 
the  surgeon  should  avoid  injury  to  these   delicate   granulations. 


712  FRACTURES   AND    DISLOCATIONS 

Tlu'  use  of  antiseptics  siieli  as  bichlorid  of  mercury  will  do  more 
harm  than  good.  AVliile  liealint;-  and  union  are  taking  place  the 
surgeon  should  see  to  it  that  the  plaster  soh'  properly  maintains 
tile  ai'eh  of  llie   foot. 

Operative  Treatment.  -( )itei'ali(»ii  is  riMMjiiently  indicated  because 
the  I'l'acture  is  conipduiid  Iml  rarely  to  accniii|)lisli  i-ediict ion.  The 
treatment  of  eompountl  eases  is  the  same  in  fractures  of  these  bones 
as  has  already  been  indicated  under  the  heading  of  ''The  Treat- 
ment of  Compound  Fractures"  on  page  7S!).  In  severe  crushes 
of  tlie  foot  iniiiiediate  amputation  is  not  infre(iuently  denumded. 

After-Treatment. — The  length  of  tlu'  period  of  immobilization 
varies  greatly  with  the  severity  of  the  fraetui'e  and  whether  or  not 
it  is  compound.  If  the  arch  of  the  foot  has  been  involved,  by  the 
fracture  or  luxation,  weight  should  not  be  borne  on  the  injured 
mend)er  inside  of  six  weeks.  In  instances  in  which  this  has  not 
occurred  the  patient  may  begin  the  gradual  resumption  of  func- 
tion at  the  end  of  three  or  four  weeks.  If  sloughing  of  the  tissues 
on  the  dorsum  of  the  foot  takes  place  union  is  usually  delayed  and 
the  period  of  fixation  should  be  prolonged  accordingly. 

Prognosis. — In  severe  crushes  of  the  foot  amputation  may  be 
necessary.  In  instances  in  which  the  trauma  has  not  been  severe, 
with  little  displacement,  and  no  sloughing  of  the  soft  tissues,  com- 
plete restoration  of  function  is  the  rule.  Surprisingly  good  func- 
tion not  infrequently  follows  even  in  compound  cases  and  in 
instances  in  which  the  soft  tissues  have  sloughed. 


CHAPTER  LIV. 

TARSO-METATARSAL  LUXATIONS. 

Surg-ical  Anatomy. — The  articulation  between  the  distal  tarsals 
(three  cuneiforms  and  cuboid)  and  the  bases  of  the  five  metatar- 
sals is  firmly  supported  by  heavy  ligaments,  and  luxations  are 
rare.  Displacements  of  the  bases  of  the  metatarsals  may  occur, 
but  the  causative  trauma  is  more  likely  to  produce  fracture  in  this 
region.  The  anterior  end  of  the  long  plantar  ligament  is  attached 
to  the  bases  of  the  second,  third  and  fourth  metatarsals.  All  five 
metatarsals  may  be  luxated  as  a  row,  or  the  base  of  any  one  may 
be  dislocated  alone.  The  displacement  is  almost  invariably  dorsal, 
so  that  the  base  of  the  metatarsal  may  be  palpated  on  the  dorsum 
of  the  foot.  Luxation  of  the  first  metatarsal  alone  is  the  most 
common  single  luxation.  The  dorsum  of  the  foot  is  slightly  short- 
ened. Divergent  luxations  have  been  noted  in  which  the  bases  of 
the  outer  metatarsals  are  displaced  outward,  while  the  inner  bones 
of  this  row  are  displaced  inward. 

Symptoms. — The  dorsum  of  the  foot  is  slightly  shortened,  and  a 
little  more  prominent  than  normal.  Pain  is  experienced  in  walk- 
ing and  when  pressure  is  made  on  the  ball  of  the  foot  by  the  sur- 
geon. Crepitus  is  absent  unless  the  luxation  is  accompanied  by 
fracture,  which  is  not  uncommon.  If  the  foot  is  carefully  com- 
pared with  the  opposite  foot  the  deformity  will  be  noted  at  the 
level  of  the  tarso-metatarsal  articulation.  Pressure  on  the  ball  of 
the  foot  may  increase  the  deformity  on  the  dorsum,  as  the  corre- 
sponding metatarsal  is  displaced  upward  and  backward. 

Diagnosis. — If  swelling  is  pronounced  it  may  be  difficult  to  differ- 
entiate between  luxations  of  this  joint  and  fractures  of  the  ad- 
joining bones,  without  the  aid  of  the  X-ray.  AVhen  the  traumatic 
reaction  is  not  great  the  landmarks  on  the  foot  will  serve  to  dis- 
close the  nature  and  position  of  the  lesion. 

Treatment. — Traction  on  the  foot  will  accomplish  reduction.  The 
foot  should  be  fixed  for  a  period  sufficiently  long  to  allow  healing 
of  the  ligaments.  The  treatment  of  luxations  at  this  joint  is  simi- 
lar to  other  dislocations  in  the  tarsus. 

713 


CHAPTER  LV. 

FRACTTTRES  OF  THE  IMETATARSALS. 

Surgical  Anatomy. — The  metatarsal  bones  are  classed  among  the 
long  bones.  The  extremities  are  composed  largely  of  cancellous 
tissue  encased  in  a  thin  layer  of  compaet  bone.  The  shafts  consist 
of  a  heavy  tube  of  compact  tissue.  Accordingly,  the  nature  of  the 
fracture  varies  with  the  region  of  the  bone  broken.  The  outer  four 
metatarsals  are  ossitied  by  two  cent'ers,  one  for  the  shaft  and  one 
for  the  head  (the  distal  end).  That  for  the  shaft  appears  about 
the  seventh  week,  while  the  epiphyseal  center  is  first  seen  during 
the  third  year.  Ossification  of  the  epiphyseal  cartilage  occurs  be- 
tween the  eighteenth  and  twentieth  years.  The  first  metatarsal  is 
diflferent  from  the  other  four.  The  liead  and  shaft  are  ossified 
from  one  center  which  makes  its  appearance  in  the  seventh  week. 
The  base  is  the  epiphysis  and  its  center  is  first  seen  during  the 
fifth  year.  Fusion  occurs  between  the  eighteenth  and  twentieth 
years.  Not  uncommonly  there  is  also  an  epiphysis  for  the  head  of 
the  bone.  When  the  first  metatarsal  shows  two  epiphyses  it  re- 
sembles both  metatarsal  and  phalanx.  These  facts  concerning  the 
ossification  of  the  metatarsals  are  of  importance  in  examining 
Rontgenograms  of  this  region  in  persons  under  twenty  years  of  age. 

The  bases  of  the  metatarsals  are  firmly  bound  to  the  distal  tar- 
sals and  to  each  other  by  heavy  ligaments,  and  like  the  tarsals  are 
seldom  luxated.  The  long  plantar  ligament  is  attached  to  the 
ventral  aspect  of  the  bases  of  the  second,  third  and  fourth  meta- 
tarsals. The  distal  ends  of  the  metatarsals  do  not  articulate  with 
each  other  but  are  held  in  position  by  the  transverse  metatarsal 
ligament.  This  ligament  tends  to  prevent  overriding  deformity  of 
the  shaft  in  the  presence  of  fracture  of  one  of  the  metatarsals. 
Aside  from  the  tendons  of  the  long  extensors  playing  over  the 
dorsum  of  the  foot  the  metatarsals  are  practically  subcutaneous. 
The  scant,  soft  tissues  covering  the  bones  in  this  region  offer  little 
protection  from  direct  violence  when  applied  to  the  dorsum  of  the 
foot. 

714 


FRACTURES   OF    THE    METATARSALS 


715 


Fractures  of  the  metatarsals  are  almost  invariably  the  result  of 
direct  blows  and  are  frequently  seen  in  crushes  of  the  foot.  Frac- 
ture from  indirect  violence  does,  however,  occasionally  occur,  espe- 
cially of  the  first  and  fifth.     A  misstep  or  twist  of  the  foot  may 


Fis.   781. 


Fig.    782. 
Figs.    781    and    782. — Show    fractures    of    the   ba.ses    of    the    fifth    metatarsals. 

produce  fracture  of  one  of  the  metatarsals.  The  injury  has  been 
noted  in  soldiers  at  the  end  of  long,  forced  marches.  The  base  of 
the  fifth  metatarsal  is  prominent,  and  falls  on  the  foot,  with  the 
member    inverted,    not    uncommonly    result    in    fracture    of    the 


716 


FRACTURES    AND    ])|SI  ,(iCAT10NS 


l)i'oximiil  jiortioii  of  this  hone.  Fracture  of  the  metatarsals  is  not, 
as  a  rule,  acconipaiiii'd  by  impaction  and  (lispjaccincnt,  as  is  the 
cast'  wlicn  tlu'  iiictacarpals  ai'c  lu'okcii. 


Fig:.  7.S 


FiiC.    ■7.S4. 


Fig.    783. — Oblique    frjictuio    of    tlie    shaft    of    tlic    tiftli    nietatiiisal. 
Fia;.    784. — Fracture  of  the  h'asr-  of  the  fiftli   metatarsal. 


Fig.  785. — Compound  crushin<r  injury  of  metacarpus  in  which  eight  di.stinct  frac- 
tures may  be  seen.  Result  of  eiglit-ton  girder  falling  on  foot.  Same  case  as  shown  in 
Fig.   787. 

Symptoms. — The  symptoms  vary  greatly  with  the  severity  of  the 
injury.  In  eases  produced  by  comparatively  slight  trauma,  and 
in  those  due  to  muscular  action  the  symptoms  will  be  moderate 


FRACTIJHES    OF    THE    METATAKSMjS 


717 


and  more  or  less  typical.  In  severe  crushes  o£  the  foot  it  is  not 
uncommon  to  be  able  to  see  the  fractured  bones  in  among  the 
lacerated  and  mangled  tissues  of  the  foot.     In  siidi   iiistfincfs  the 


Fig.  786. — Method  (if  dctiM-tiiii;-  fvactdvcK  in  tlie  iiictai-iiriials.  I'l-cssure  on  the 
metacarpal  head  in  the  line  of  the  long  axis  of  the  bone  will  elicit  puiu  in  the  presence 
of  fracture. 


Fig.  787. — Crushing  injury  of  the  foot.  An  eight-ton  girder  fell  on  the  foot  as  it 
■was  resting  on  the  edge  of  a  curb,  producing  eiglit  fractures  in  the  metacarpal  bones. 
(See  X-ray,  Fig.  785.)  The  wound  seen  in  the  plate  resulted  from  subsequent  slough- 
ing and  it" was  possible  at  one  time  to  see  four  of  the  fractures  of  the  metatarsals.  Wound 
healed  by  cultivation  of  granulation  tissue  rather  than  attention  to  antisepsis.  Result: 
union  in  all  the  fractures  with  closure  of  the  wound  and  perfect  recovery  of  function. 
Patient  walks   without  limp. 


fractures  present  are  only  of  secondary  importance  as  compared 
with  the  damage  done  to  the  soft  parts.  Sloughing  of  the  tissues 
on  the  dorsum  of  the  foot  is  not  an  uncommon  sequel  when  the 
causative  trauma  has  been  severe  and  direct.     In  crushes  of  the 


718  FRACTURES   AND   DISLOCATIONS 

foot  there  will,  of  course,  be  complete  loss  of  function.  In  simple 
eases  pain,  tenderness,  swelling,  crepitus  and  abnormal  mobility 
will  be  present.  The  suffering  is  increased  if  the  patient  attempts 
to  stand  on  the  foot,  and  in  some  instances  the  fragments  may  be 
heard  grating  against  one  another  as  the  attempt  is  made.  De- 
formity is  rarely  pronounced.  In  one  exceptional  compound  case 
seen  by  the  author  there  was  a  fracture  of  the  sliaft  of  the  first 
metatarsal,  a  little  below  the  middle,  and  the  distal  fragment  was 
turned  completely  around  on  a  transverse  axis,  so  that  the  articular 
end  rested  against  the  distal  end  of  the  ]>roximal  fragment. 

Diagnosis. — There  is  usual!}'  little  difficulty  in  recognizing  a  frac- 
ture of  one  or  more  of  these  bones.  Their  dorsal  surfaces  are 
practically  subcutaneous,  and  if  the  case  is  seen  early  much  can 
be  learned  by  direct  palpation.  If  the  swelling  and  traumatic 
reaction  are  well  advanced  before  the  surgeon  is  called,  the  parts 
may  be  exciuisitel.y  tender,  and  under  such  circumstances  it  is 
preferable  to  determine  the  presence  of  fracture  by  tlie  use  of  the 
X-ray,  rather  than  to  administer  an  anesthetic  and  establish  the 
diagnosis  by  palpation  and  manipulation. 

If  pressure  is  made  on  the  ball  of  the  foot  (between  the  toes  and 
the  ball)  and  toward  the  base  of  the  bone  (that  is,  in  the  direction 
of  the  axis  of  the  metatarsal)  pain  may  be  produced  at  the  seat  of 
fracture  in  the  corresponding  bone.  Pressure  should  be  made  in 
this  way  over  the  head  of  each  metatarsal. 

Treatment. — The  foot  should  be  placed  on  a  plaster  sole  which  is 
moulded  so  that  it  properly  supports  the  arch  of  the  foot.  This 
splint  should  extend  from  the  middle  of  the  leg  to  a  point  beyond 
the  toes.  Traumatic  reaction  should  be  controlled  by  the  inter- 
mittent application  of  the  ice  cap,  and  by  keeping  the  foot  in  the 
elevated  position.  If  deformity  exists  it  should  be  corrected  be- 
fore the  plaster  sole  is  applied. 

Operative  Treatment. — Compound  cases  are  common  and  the 
operative  treatment  in  these  cases  is  practically  the  same  as  that 
given  on  page  712  under  "Fractures  and  Dislocations  of  the 
Cuboid,  Scaphoid  and  Cuneiforms."  Open  treatment  to  correct 
deformity  in  simple  cases  is  practically  never  indicated. 

After-Treatment. — Union  takes  place  in  simple  cases  in  three  to 
four  weeks.  Weight  bearing  should  be  only  gradually  resumed, 
since  ventral  bowing  may  occur  if  the  first  metatarsal  alone  or 
more  than  one  of  the  other  metatarsals  has  been  broken,  and  the 


PRACTIIKKS    OF    Till':    METATARSALS  739 

patient  walks  too  soon.  Hot  applications,  passive  motion  and  mas- 
sage will  hasten  the  time  when  the  patient  will  be  able  to  enjoy 
free  use  of  the  foot. 

Prognosis. — The  seventy  of  these  lesions  varies  gi-eatly,  and  ac- 
cordingly the  outlook  will  depend  on  the  amount  of  damage  done. 
Simple,  uncomplicated  injuries  should  be  followed  by  complete 
restoration  of  function.  Severe  crushing  injuries  may  require  im- 
mediate amputation. 


CHAPTER  LVI. 
FRACTURES  AND  LUXATIONS  OF  THE  PHALANGES. 

Surgical  Anatomy. — The  structure  of  the  bones  of  the  toes  is 
similar  to  that  found  in  the  tinkers.  Tlie  toes  may  be  broken  in 
crushes  of  the  foot,  and  resemble  the  eondition  as  occurring  in  the 
metatarsals.  The  toes  are  practically  always  broken  by  direct  vio- 
lence. The  accident  is  common  among  laborers  and  results  from 
heavy  objects  being  dropped  on  the  foot.  A  not  uncommon  form 
of  injury  is  one  in  which  the  toes  are  caught  in  a  moving  elevator. 
The  great  toe  usually  suffers  most  and  the  crushiug  of  the  parts 
is  severe  when  produced  in  this  way.  Stubbing  of  the  toes  against 
some  projecting  object,  while  the  patient  is  barefooted,  is  fre- 
quently responsible  for  fracture  of  one  or  more  of  the  phalanges, 
especially  that  of  the  little  toe.  Luxations  of  the  toes  are  rare  and 
resemble  those  seen  in  the  fingers. 

Symptoms.— The  amount  of  disability  is  almost  entirely  de- 
pendent on  the  severity  of  the  causative  trauma.  In  simple  frac- 
ture of  the  little  toe  the  patient  is  usually  able  to  get  about  with 
little  difficulty  although  pain  may  be  severe  immediately  following 
the  accident.  On  the  other  hand  severe  crushing  injuries,  such  as 
sustained  in  the  usual  elevator  accident,  completely  disable  the  pa- 
tient. Crepitus,  pain  and  swelling  are  present.  Crepitus  may  be 
difficult  to  elicit  if  the  fracture  is  in  the  distal  phalanx,  because  of 
the  splinting  effect  of  the  nail. 

Treatment. — The  parts  should  be  immobilized  on  a  plantar  splint. 
The  displacement  is  usually  moderate  and  can  be  corrected  without 
difftculty.  In  fractures  of  the  great  toe  the  patient  should  be  pre- 
vented from  bearing  weight  on  the  foot  until  union  is  solid.  In 
fracture  of  the  smaller  toes  the  patient  may  be  allowed  about  as 
soon  as  the  traumatic  reaction  has  subsided.  The  great  toe  is  an 
important  factor  in  walking  but  the  lesser  toes  have  little  to  do 
with  the  usefulness  of  the  foot.  If  fibrous  union  takes  place  in 
one  of  the  smaller  toes  there  will  be  no  subsequent  disturbance  in 
function.     When  the  little  toe  alone  is  fractured  it  will  usually 

720 


FRACTURES   AND   LUXATIONS   OF   PHALANGES  721 

not  he  necessary  to  employ  a  splint  in  the  treatment  of  the  (condi- 
tion. If  cotton  is  placed  between  the  little  toe  and  the  adjoining 
digit,  and  the  injured  toe  strapped  in  position  with  adhesive,  the 
necessary  immobilization  will  have  been  accomplished.  In  com- 
pound, crushing  injuries  the  important  element  is  the  damage  done 
to  the  soft  tissues,  and  the  case  must  be  treated  accordingly.  Gan- 
grene may  develop  in  one  or  more  of  the  toes  if  the  crushing  has 
been  severe,  and  amputation  may  be  necessary. 

Prognosis. — In  simple  uncomplicated  cases  the  prognosis  is  good. 
If  the  accident  results  in  the  loss  of  the  great  toe  there  may  be  a 
limp,  more  or  less  noticeable  in  the  patient's  gait. 


PART  IV. 
SPECIAL  SUBJECTS. 


CHAPTER  LVII. 

TERMS  AND  DEFINITIONS. 

Fracture. — No  better  definition  can  be  given  than  the  meaning 
of  the  Latin  word  {f ranger e,  to  break)  from  which  the  term  is  de- 
rived.    A  breaking  of  bone  or  cartilage. 

Dislocation  or  Luxation. — Is  a  condition  in  which  the  articular 
surfaces  are  completely  displaced  from  each  other.  These  terms 
are  often  loosely  used,  and  in  many  instances  an  incomplete  dis- 
placement of  the  articular  surfaces  is  spoken  of  as  a  dislocation 
when  it  should  be  designated  as  a  subluxation. 

Subluxations  are  dislocations  in  which  the  articular  surfaces  re- 
main partly  in  contact  with  each  other. 

Complete  and  incomplete  are  terms  used  to  indicate  the  degree 
of  fracture  or  luxation.  In  incomplete  fractures  the  line  of  frac- 
ture only  partially  separates  the  fragments. 

Congenital  fractures  and  luxations  are  conditions  which  exist  at 
birth.  In  many  instances  it  is  difficult  to  state  whether  or  not  the 
lesion  was  intra-uterine.  Congenital  fractures  and  luxations  may 
be  the  result  of  prenatal  disease,  defective  development  or  of 
trauma  at  birth,  or  of  a  combination  of  these  causes. 

Spontaneous  fractures  and  dislocations  occur  as  a  result  of  dis- 
ease or  paralysis.  In  some  instances,  notably  fracture  of  the  hip, 
the  bone  may  break  under  normal  strain  as  a  result  of  the  absorp- 
tion and  rarefication  of  bone  which  takes  place  in  the  aged. 

Pathologic  fractures  are  caused  by  diseases  of  the  bone  such  as 
osteo-sarcoma,  carcinoma,  osteo-myelitis,  etc. 

Pathologic  luxations  result  from  diseases  which  cause  degener- 
ation of  the  ligaments  or  alterations  of  the  articular  surfaces. 

Recurrent  or  habitual  luxations  are  conditions  in  which  the  same 
dislocation  takes  place  repeatedly,  following  incomplete  healing  of 
the  ligaments  after  the  initial  lesion.  Recurrent  luxations  are  com- 
mon in  the  shoulder  joint  following  improper  treatment  of  the  first 
displacement. 

Diastasis  and  distraction  are  terms  used  to  indicate  a  condition 

725 


726  FRACTURES    AMI    DISLCXWTIONS 

in  Avliich  the  joint  surfaces  are  forcibly  torn  from  each  other  and 
remain  separated  without  overriding  deformity.  A  good  example 
of  diastasis  is  sometimes  seen  in  the  lower  tibio-fibular  articulation 


Fig.   788.  Fig.   789. 

Fig.    788. — Example    of    a    simple    trimsverse   fracture. 
Fig.   789. — E.\ample    of    multiple    fracture    of    the    shaft. 

when  the  ligaments  are  torn  and  the  lower  ends  of  the  tibia  and 
fibula  separated. 

The  term  compound  or  open  is  used  when  the  fracture  or  lux- 
ation is  connected  with  the  outside  air  by  means  of  a  wound.  The 
wound  may  be  made  by  the  vulnerant  body  penetrating  to  the 


TKRMS    AND    DKKINITIONS 


727 


bone,  or  the  end  of  the  fragment  or  articular  surface  of  the  bone 
may  penetrate  the  skin  from  witliin. 

The  term  closed  is   used  in   contradistinction   to   open   or   com- 
pound. 


Fig.    790. 


Fig.   791. 


Figs.  790  and  791. — Surface  form  and  section  of  fracture  united  in  deformity.  Old 
fractured  tibia  sawed  in  tlie  coronal  plane.  Note  how  the  rough  fractured  surfaces  not 
originally  in  apposition  have  been  absorbed,  filled  in  and  rounded  off,  as  the  middle  of 
the  callus  became  more  dense.  When  union  takes  place  with  deformity,  as  in  this  case, 
the  callus  is  of  necessity  heavier  and  more  dense  than  when  good  reduction  has  been 
accomplished.  This  specimen  was  obtained  from  the  dissecting  room  and  is  probably 
many  years  old  yet  the  medullary  canal  has  not  reopened.  In  fractures  of  the  shafts 
of  long  bones  the  medullary  canal  reopens  some  years  following  the  injury  provided  the 
reduction  is  good.  In  this  case  the  deformity  is  pronoimced  and  the  medullary  canal 
remains  occluded  by  the  internal  callus.  A  good  example  of  the  reopening  of  the  canal 
is  seen  in  the  X-ray  plates    (Pigs.   636  to  639). 


The  term  simple  is  used  in  contradistinction  to  both  compound 
and  complicated. 

The  term  complicated  is  rather  indefinite  in  its  meaning.  It  is 
used  when  the  fracture  is  compound  or  open  and  is  also  employed 


728 


FRACTURES   AND   DISLOCATIONS 


to  indicate  asjsot'iatLtl  injury  to  arteries,  veins,  nerves  or  muscles. 
It  is  also  used  when  the  fracture  is  infected. 

A  green-stick  fracture  is  one  in  which  the  line  of  fracture  re- 
sembles that  seen  when  a  green-stick  is  broken.     The  bone  is  bent 


Fig.   792. — Carcinoma  of  the  humerus  with  spontaneous  fracture. 
Fig.    793. — Carcinoma    of    the    humerus    with    spontaneous    fracture. 

and  the  fracture  involves  only  the  convex  side  of  the  shaft.  Many 
fractures  are  called  green-stick  which  are  in  reality  of  the  sub- 
periosteal type. 

Suhperiosieal  fracture. — This  term  is  used  when  the  fracture  is 


TERMS    AND    DEFINITIONS 


729 


Fig.    794. — Carcinoma   of   the   lower    end   of   the   femur   with   extensive    destruction   of 


f30 


FRACTURES    AND    DISLOCATION'S 


Fig.    795. — Syphilitic    dactylitis   with    siioiilancdus    fracture. 


Fig.    796. — Spontaneous   fracture   following   osteosarcoma. 


TERMS    AND   DEFINITIONS 


731 


not  accompanied  by  appreciable  tearing  of  the  periosteum  or  dis- 
placement of  the  fragments.  It  occurs  in  children  and  is  the  result 
of  bending  force  applied  to  the  bone.     When  this  type  of  violence 


Fig.    797. — Osteocarciiioma    with   spontaneous   fracture.      Much   destruction   of   bone. 

is  applied  to  a  young  bone  (young  bones  are  tough  rather  than 
brittle)  the  convex  side  of  the  shaft  is  under  tension  strain  while 
the    concave    side    is    under    compression    strain.     Fracture    may 


732 


FRACTURES   AND   DISLOCATIONS 


"^9 


TERMS    AND    DEFINITIONS 


733 


Fig.    799. 


Pig.    800. 


Fig.    799. — Same  case  as  shown  in  Fig.   798.      Note  fraoture  of  femur. 
Fig.   800. — ^Same   case.      Note    fracture    of   femur. 


Fig.   801. 


Fig.    SO 2. 


Fig.    801. — Same   case.      Note  bowing   of   tibia   and  point   in   shaft   which   is  ready   to 
break  with  the  slightest  strain. 

Fig.  802. — Same  case.     Same  condition  as  seen  in  tibia  of  opposite  leg  in  Fig.  801. 


7o4  FRACTrRES    AXU    DISLOCATIONS 

occur  on  tlie  convex  side  from  tension  or  on  the  concave  side 
from  compression.  Wlien  the  former  type  of  fracture  occurs  and 
is  incomplete  we  luive  tlie  lypical  ,ureen-stiek  fracture.  AVhen 
the  latter  type  occurs  we  have  tlie  suh])eriosteal  form  of  fracture. 
Tlie  ditference  is  well  illustrated  hy  the  manner  in  which  different 
forms  of  iron  hrcak.  \Vi'(Miiili1  ii'on  <iii'ders  break  on  the  concave 
side  from  ■'bucklini>-, "  wliiU'  steel  girders  break  on  the  convex 
side  with  clean  fradui-e.  The  more  brittle  the  material  the  more 
likely  the  fracture  is  to  begin  on  the  convex  side  of  the  column  and 
to  be  conij>lete.  The  more  rapid  the  liending  the  greater  the  proba- 
bility of  a  complete  fracture  and  of  the  l)reak  lieginning  on  the 
convex  side. 

Various  terms  are  used  to  indicate  the  nature  of  the  fracture, 
the  character  of  the  deformity  and  the  line  of  the  break.  Such 
commonly  used  terms  as:  comminuted,  multij)le.  transverse,  oblique, 
spiral,  overriding,  angular,  depressed,  etc.,  are  self-explanatory. 


CHAPTER  LVIII. 

THE  USE  OP  THE  X-RAY. 

BY   H.    G.    STOVER,    M.D. 

After  the  lapse  of  some  eighteen  years  since  Rontgen's  discovery, 
it  ought  not  to  be  required,  in  a  work  upon  fractures  and  disloca- 
tions, to  insist  upon  the  absolute  necessity  for  the  routine  use  of  this 
indispensable  diagnostic  means  in  every  instance  of  possible  bone 
or  joint  injury. 

Yet  even  in  this  day,  when  the  benefits  of  Rontgenology  are  avail- 
able in  so  many  localities,  the  use  of  this  agent  is  far  from  as 
general  as  it  should  be. 

In  the  early  days  of  the  Rontgen  ray  there  was  some  excuse  for 
the  surgeon  who  did  not  rely  upon  it :  the  users  of  the  ray  were  not 
in  possession  of  efficient  apparatus ;  exposures  were  long,  and  often 
resulted  in  harm ;  and,  owing  to  imperfect  technique  and  small 
experience,  the  information  afforded  by  a  Rontgenologic  examina- 
tion was  in  many  instances  incomplete,  and  at  times  misleading. 

These  excuses  do  not  hold  now ;  in  every  center  of  population 
there  are  installations  capable  of  giving  useful  Rontgenograms,  and 
men  who  are  competent  to  make  the  examinations  skillfully  and 
without  danger  to  the  patients. 

The  advantages  of  the  Rontgenologic  examination  are  many  and 
vital. 

The  Rontgen  examination  does  away  with  the  need  for  manipu- 
lation of  injured  parts  in  the  attempt  to  elicit  pain,  crepitus  and 
preternatural  mobility;  it  not  only  affords  all  the  information  of 
value  to  be  gained  from  the  ordinary  methods  of  examination,  but 
it  brings  forth  facts  impossible  to  be  elicited  in  any  other  waj': 
certain  fractures  without  displacement ;  certain  impacted  fractures ; 
certain  incomplete  fractures;  certain  fractures,  which,  by  their 
very  nature  cannot  give  the  usual  clinical  signs ;  it  reveals  the  inter- 
position of  small  fragments  between  the  ends  of  fractured  bones; 
and  avoids  the  bruising  and  laceration  of  tissues  which  must  occur 
in  some  instances  if  there  be  a  prolonged  manipulative  examination. 

735 


736  J^RACTURES   AND    DISLOCATIONS 

It  has  been  argued  by  some  that  a  surgeon  ought  not  allow  his 
manual  dexterity  to  suffer  the  atrophy  of  disuse,  by  relying  upon 
the  Rontgen  ray ;  one  might  as  well  say  that  an  internist  ought  not 
use  the  microscope  to  look  for  plasmodia  in  the  blood,  but  ought 
rather  nurse  his  skill  in  eliciting  subjective  and  objective  clinical 
synijitoins  upon  which  to  formulate  his  diagnosis.  At  the  same 
time,  it  must  be  insisted  that  the  Rontgen  examination  is  not  to 
supplant  the  clinical  methods;  rather  nuist  it  supplement  them. 
The  skilled  hand  of  the  surgeon  has  done  its  wonders  through  the 
ages ;  it  cannot  be  neglected  now ;  the  practised  eye  discovers  ex- 
ternal signs  of  internal  conditions  in  a  marvelous  way  as  evidenced 
by  the  photographs  in  this  book. 

The  time  is  coming  when  failure  to  make  appropriate  use  of 
Rontgenology,  when  accessible,  will  be  counted  as  negligence,  and 
this  not  only  in  surgery,  but  in  many  departments  of  internal 
medicine.  Even  the  laity  are  coming  now  to  criticise  their  attend- 
ants for  delay  or  neglect  in  this  matter. 

After  attempted  reposition  of  fracture  or  dislocation,  the  Rontgen 
examination  affords  a  means  of  ascertaining  if  position  is  correct 
without  disturbing  retentive  dressings  or  apparatus,  enables  one  to 
watch  the  course  of  healing,  and  to  know  the  final  anatomical  result. 

In  many  of  the  fractures  met  with,  a  clinical  diagnosis  sufficiently 
accurate  for  preliminary  treatment  can  be  made ;  in  these  cases  the 
Rontgen  examination  should  be  made  after  reposition  in  order  to 
check  up  the  clinical  diagnosis  and  to  make  certain  that  satisfactory 
reposition  has  been  accomplished.  But  there  are  not  a  few  in- 
stances in  which  the  Rontgen  examination  should  be  made  before 
anything  else  is  done ;  in  this  class  are  many  of  the  injuries  about 
the  elbow^,  hip,  and  pelvis,  and  those  severe  traumata  in  which  there 
is  suspicion  of  grave  damage  to  vital  soft  tissues,  and  further  injurj'^ 
through  manipulation  might  result  in  gangrene,  or  other  detri- 
mental sequelae. 

As  the  Rontgen  ray  produces  no  sensory  impression  upon  the 
retina,  it  is  necessary  to  use  intermediate  means  to  transform  the 
results  of  its  energy  into  visible  records. 

There  are  three  physical  factors  which  render  this  possible : 

First:  all  substances  absorb  the  Rontgen  ray  practically  in  rela- 
tive amounts  corresponding  directly  to  the  ratio  existing  between 
their  atomic  weights. 

Second :  the  Rontgen  ray  causes  certain  substances  to  fluoresce. 


THE    USE   OF   THE   X-RAY  737 

Third :  the  Rontgen  ray  has  the  power  of  producing  a  paralyzing 
effect,  or  a  latent,  developable  image,  upon  the  chemicals  used  in 
the  sensitive  emulsion  of  photographic  plates  and  certain  photo- 
graphic papers. 

If  a  substance  is  so  placed  that  it  will  intercept  rays  directed 
toward  a  screen  coated  with  fluorescent  material,  or  a  photographic 
plate,  the  absorption  which  occurs  leaves  areas  on  the  screen  or 
emulsion,  which  are  not  affected ;  these  areas  on  the  fluorescent 
screen  are  dark;  in  the  emulsion  of  the  plate  no  latent  image  is 
produced ;  if  the  substance  'under  examination  is  made  up  of  areas 
of  various  densities,  the  amount  of  fluorescence  upon  the  screen  or 
of  alteration  in  the  silver  salt  of  the  emulsion  of  a  plate,  in  corre- 
sponding areas,  varies  in  an  inverse  proportion  to  the  densities  of 
these  areas,  or  in  direct  ratio  to  the  amount  of  rays  which  these 
areas  permit  to  pass. 

At  the  present  time  the  fluoroscope  is  not  used  in  this  branch  of 
surgical  Rontgenology,  except  for  roughly  and  quickly  estimating 
the  approximate  location  of  a  foreign  body,  or  obtaining  some 
general  facts  regarding  a  bone  injury;  the  screen  image  is  not  so 
rich  in  detail  as  is  that  upon  the  plate ;  it  can  be  studied  during 
only  a  short  period  of  time ;  it  is  not  a  permanent  record ;  its  fre- 
quent use  is  dangerous  to  the  operator;  long  or  repeated  exposure 
may  lead  to  injury  of  the  patient's  skin,  as  for  example,  when  the 
operator,  the  attending  physician,  perhaps  a  consulting  surgeon, 
and  probably  from  one  to  a  dozen  relatives  and  friends,  must  all 
' '  have  a  look. ' '  On  the  other  hand  the  sensitive  plate  gives  all  the 
details;  it  can  be  studied  as  long  or  as  often  as  needed  and  at  any 
time ;  it  is  a  permanent  record  of  the  condition ;  it  is  demonstrable 
evidence  that  such  an  examination  has  been  made ;  in  addition  to 
this,  the  accumulation  of  a  large  library  of  plates  furnishes  rich 
material  for  scientific  study  and  for  the  writing  of  papers. 

The  great  part  of  Rontgen  diagnosis  in  medicine  and  surgery 
must  be  done  by  specialists  in  this  line,  and  indeed  before  long  there 
will  be  subspecialties  in  Rontgenologj^,  so  great  is  the  field  and  so 
complicated  the  technical  details  of  diagnosis-making.  jNIost 
physicians  and  surgeons  will  find  it  impracticable  to  make  their 
own  Rontgen  examinations.  A  complete  equipment  is  costly  in 
apparatus  and  space  and  its  maintenance  expensive.  One's  own 
patients  will  not  contribute  as  liberally  to  this  for  these  examina- 
tions as  they  will  do  when  referred  to  a  specialist  for  the  purpose, 


TAS 


FKACTIRKS    AND    DISLUCATIUXS 


and  men  cainiot  irivc  tiinc  iVoiu  a  busy  prnctico'  to  carry  out  the 
woi-k.  The  i)liy.si('ian  who  docs  not  have  reasonably  ready  access 
to  a  competent  Hiintgenologist  nia\-  wdl.  howevei-,  pi'ep.-ii-e  and  ccpiip 
luinsclf  to  examine  fi'actnres  and  dislocations  by  this  nu'thod.  lie 
will  not  need  the  jiowerfnl  wencratinsi'  machines,  tlie  com])licated 
auxiliary  ap|)aratiis  or  the  costly  tubes  nccessai-y  I'oi-  instantaneous 
Rontgenoi'ra{)hy  ot  the  luniis  and   stomach,      ^'ct    lei    not    such   an 


Fig.    803. — The  Kose  i)(irtiililc  coil. 


one  imagine  that  he  is  taking  up  a  simple  problem!  For  this  man 
the  author  would  advise  the  Rose  Portable  Coil  (Fig.  803).  It  may 
be  used  on  either  direct  or  alternating  current;  it  is  of  the  compact 
"suit-case"  type  and  can  be  carried  in  the  hand  for  short  distances 
without  overfatigue,  so  it  may  be  used  either  in  the  office  or  at  the 
beside  where  electric  current  is  available.  In  Fig.  804  is  shown  a 
larger  apparatus  of  the  same  type.     It  is  more  powerful  but  is 


THE    TISK    OF    Tlir-:    X-RAY 


739 


more  weighty  and  heavier  fuses  must  \h'  phieed  in  house  eii-euits  in 
which  it  is  used.  Another  box  for  carrying  the  Crooke's  tube  and 
the  plate-holders  is  a  convenience.  The  apparatus  requires  a  special 
type  of  Clrooke's  tube,  calculated  to  suppress  inv(!r.se  current  (Fig. 

805). 


Fig.  804. — This  apparatus  is  similar  to  tliat  sliown  in  preceding  figure.  It  is.  liow- 
ever,  more  powerful  and  more  weighty.  Heavier  fuses  must  be  placed  in  the  house 
circuits  on  which  it  is  used. 


The  Cramer,  the  Forbes,  or  the  "Agfa"  X-ray  plates  will  be 
found  quite  satisfactory,  permitting  of  some  latitude  in  exposure 
time. 

These  plates  are  to  be  enclosed  in  the  black  and  yellow  envelopes. 


r40 


FRACTURES   AND   DISLOCATIONS 


Opaque  to  ordinary  actinic  light,  wliicli  may  be  procured  from  the 
plate  makers.  Always  put  the  plate  in  the  black  envelope  (in  the 
dark-room,  of  course)  so  that  the  film  of  the  plate  is  next  to  the 
smooth  side  "of  the  envelope;  then  put  the  black  envelope  into  the 
yellow  one  so  that  their  smooth  and  unprinted  sides  are  together; 


Fij.    805. — Special  type  of  Crookes  tube,   calculated   to  suppress   inverse  current. 

this  is  important,  as  in  this  way  one  is  always  certain  as  to  which 
side  of  the  package  carries  the  film  side  of  the  plate.  If  Rontgeno- 
grams  are  made  with  the  tilm  side  of  the  plate  down  in  some 
examinations  and  up  in  others,  when  using  envelopes,  there  might 
he  no  way  of  knowing,  in  a  subsequent  study  of  the  plate,  whether 


l''ig.   806. — Metallic   numbers    for    marking   X-ray    plates. 

the  right  or  left  side  of  the  body  had  been  examined,  a  point  which 
it  is  quite  necessary  to  know  when  making  reports  to  insurance 
companies,  or  when  the  physician  is  called  to  the  witness  stand.  It 
is  a  very  good  plan  to  mark  the  plates,  at  the  time  of  making  the 
exposure,  by  means  of  leaden  letters  "L"  and  "R. " 


THE    USE   OF   THE   X-RAY  741 

For  several  reasons  it  is  quite  important  that  plates  be  carefully 
so  marked  that  their  future  identification  is  always  positive.  Metal- 
lic numbers  (Fig.  806)  may  be  placed  on  the  plate  at  the  time  of 
the  exposure,  thus  obtaining  a  Rontgenogram  of  the  number  as  a 
part  of  the  image  produced;  if  this  is  not  practicable  the  number 
of  the  plate  or  the  patient's  name,  should  be  written  upon  the  film 
side  of  the  plate,  in  the  dark-room,  with  a  lead  pencil,  immediately 
before  developing  it. 

When  the  Rontgenogram  has  been  made,  the  following  points 
should  be  noted  upon  the  envelope,  for  a  record :  name  of  patient ; 
address ;  occupation ;  if  a  minor  or  a  dependent,  the  name  and 
address  of  the  financially  responsible  party ;  the  date ;  the  part 
examined;  the  nature  of  the  view — whether  antero-posterior, 
postero-anterior,  lateral,  etc.;  the  condition  suspected;  the  diagno- 
sis ;  and  other  facts  may  be  added  if  desired,  such  as,  history  of  the 
injury;  description  of  the  dressings  applied,  etc. 

The  plates  should  be  filed  away  in  a  safe  place  in  such  a  way 
that  they  will  be  readily  accessible  for  future  reference.  Filing 
may  be  done  according  to  number,  or  in  groups  of  "parts  of 
body,"  or  in  groups  of  "lesions  found."  An  index  of  such  a 
nature  that  plates  may  be  found  easily,  should  also  be  kept. 

Do  not  permit  patients  or  others  to  carry  away  your  plates ;  you 
may  want  them  badly  yourself  some  day.  The  plate  is  the  most 
important  part  of  your  record  of  your  work ;  it  may  be  needed  for 
study  of  the  progress  of  a  case ;  it  may  be  needed  in  court ;  in  time 
your  plates  form  a  valuable  library  as  already  stated. 

The  author  does  not  permit  his  plates  to  be  introduced  in  evi- 
dence as  "exhibits"  in  medico-legal  cases;  when  the  author  is  on 
the  stand  and  is  asked  to  show  his  plates  to  the  jury,  he  says  to  the 
Judge,  "May  it  please  your  Honor,  these  plates  are  a  part  of  my 
professional  records;  they  are  necessary  to  me  as  such,  and  as 
material  for  scientific  study ;  I  therefore  do  not  desire  to  introduce 
them  into  evidence  as  exhibits,  but  simply  to  use  them  as  diagrams, 
by  means  of  which  to  demonstrate  the  opinion  I  am  here  to 
give."  This  has  always  been  allowed  without  question  by  the 
Court. 

Prints,  if  they  are  of  such  a  nature  that  they  will  show  the  con- 
ditions according  to  the  opinion  of  the  expert,  may  be  introduced 
as  exhibits.  Personally  the  author  does  not  think  plates  or  prints 
ought  to  be  made  exhibits  in  evidence.     The  Rontgenologist  is  not 


742 


KUACrrRKS    AND    DISl.t  ICA'PIONS 


in   court   as  a   ])liotoc!:raph('r.   but   as  a   in(Mlico-l('«ral   expert   wliose 
oplniou  is  beiiij?  given. 

The  Rontgen  ray  is  a  form  of  energy  proceeding  in  divergent 
lines  from  its  source.  This  most  important  fact  nuist  be  borne  in 
mind  when  i)Osing  patients  for  examination  and  wlien  reading  the 
negatives  obtained.  On  .Mceount  of  this  divergence,  we  have  this 
fact  to  remeiiiher:  otlier  things  being  ecpial,  the  quantity  of  Rontgen 
ray  falling  upon  a  surface  varies  inversely  with  the  square  of  the 
distance  of  that  surface  from  the  source  of  energy.  Suppose  a 
surface  (Fig.  807)  one  foot  s(|uare  exi)osed  to  the  Rontgen  ray  at  a 
distance  of  one  foot  from  the  target  of  the  tube;  let  ^4  be  the  target 
of  the   tube:   let    lU'DK   tie  tile  surface   exposed:   then    this   s(|uai-e 


Fig.    807. 


Fig.   808. 


foot  of  surface  is  receiving  a  pyramid  of  rays  included  in  AB,  AC, 
AD,  AE ;  now  extend  these  lines  until  they  reach  a  plane  at  a  dis- 
tance of  two  feet  from  the  target  (Fig.  807),  and  they  include  the 
surface  FGHJ,  which  will  be  found  to  contain  four  square  feet ; 
therefore  the  same  pyramid  of  rays  at  one  foot  distance  covering 
one  square  foot  of  surface,  at  two  feet  distance  covers  four  square 
feet. 

Another  important  factor  in  posing  is  now  to  be  brought  out 
(Fig.  808).  Suppose  the  target  of  the  tube  at  .4,  the  object  to  be 
examined  X-Y.  If  a  plate  is  placed  at  B-C,  the  image  of  X-Y  is 
somewhat  but  very  little  magnified  on  B-C ;  but  if  now  the  plate  is 
moved  to  B'-C,  leaving  the  object  X-Y  close  to  the  target  as  before, 


THE    USE   OF    THE   X-RAY 


743 


the  shadow  of  X-Y  takes  on  the  length  B'-C,  a  very  great  distortion. 

If,    however    (P'ig.  80!)),    both    plate    and    objeet    (Examined    are 

moved   far   fi-oni   the  target,   the   image  of  X-Y  on    phite   H-(]  is 

A 


Fig.    809. 


M     N 

Fig.   810. 


much  more  nearly  the  actual  size  of  the  object  than  when  both  were 
close  to  the  target. 

Further,  pose,  for  our  ''object,"  a  sphere  containing  in  its  center 
a  smaller  and  denser  spherical  mass,  so  that  the  plate  and  the  object 


Fig.    811. 


are  near  each  other,  but  at  a  good  distance  from  the  target  A,  yet  in 
such  a  position  that  the  line  PA  (representing  the  principal  axis  of 
rays,  those  falling  perpendicularly  upon  the  plate)   pass  far  from 


744  FRACTl'KES   AND    DISLOCATIONS 

the  center  of  the  object,  as  in  Fij?.  810.  The  Klinttiviiogi-ain  result- 
ing from  tliis  ])Ose,  shown  in  Fig.  811,  iiives  a  distorted  image  of  tiie 
object.  The  outline  of  the  image  is  far  from  being  eii'cular  in  form, 
aiul  the  image  of  the  smaller  sphere  is  not  at  tlie  ceiitei-  of  the  image 
of  the  large  sphere. 

From  these  facts  Ave  ma\  deduce  a  general  rule  for  so  posing  as 
to  avoid  distortion : 

The  object  and  the  plate  sliould  be  as  ch)se  together  as  possible; 
they  should  be  as  far  as  possible  from  the  target  (consistent  with 
securing  sufficient  (luantity  of  ray)  ;  the  rays  falling  from  the  target 
perpendicularl\-  upon  the  plate  should  pass  through  the  center  of 
the  object. 

A  distance  of  from  eighteen  to  twenty-four  inches  between  tube 
and  plate  is  usually  used. 

Now  this  cannot  be  an  absolute  rule ;  it  nuist  be  infringed  upon  in 
respect  of  the  relation  of  the  principal  axis  of  rays  and  the  center 
of  the  object,  at  times.  For  example :  a  patient  with  a  suspected 
fracture  of  the  neck  of  the  femur,  exhibiting  considerable  eversion 
of  the  lower  extremity ;  as  the  patient  lies  on  his  back,  the  plane  of 
the  neck  of  the  femur  is  not  parallel  with  the  surface  of  the  plate 
placed  underneath ;  rays  passed  through  the  neck  of  the  femur  and 
falling  perpendicularly  upon  the  plate,  would  give  a  foreshortened 
image  of  the  neck,  largely  covered  by  the  superimposed  shadow  of 
the  greater  trochanter ;  therefore  the  exposure  to  show  a  fracture 
of  the  neck  of  the  femur  in  such  a  case  as  this  must  be  made 
with  the  target  of  the  tube  outside  of  a  perpendicular  from  the  plate 
passing  up  through  the  neck ;  this  oblique  direction  of  the  rays  will 
show  the  full  length  of  the  neck. 

In  making  a  Rontgenogram  of  the  ankle-joint,  antero-posterior 
view,  with  the  toe  pointing  directly  upward,  perpendicularly  to  the 
plate  beneath,  the  target  should  be  placed  a  little  to  the  outside  of 
the  perpendicular,  in  order  not  to  superimpose  the  shadows  of  the 
lower  ends  of  the  tibia  and  fibula. 

The  rays  proceeding  from  ditferent  (Jrookes  tubes  are  not  always 
the  same  in  quality ;  the  quality  of  ray  from  any  given  tube  will 
vary  from  time  to  time.  There  is  a  variation  in  quantity  depend- 
ing upon  the  exciting  current ;  beside  this,  there  are  all  degrees  of 
variation  in  penetrating  power,  dependent  largely,  apparently,  upon 
the  nature  of  the  vacuum  in  the  tube,  other  things  being  equal. 


THE    USE   OP   THE   X-RAY  745 

In  general  we  speak  of  tlie  rays  as  being  "soft,"  "meflium,"  or 
"hard,"  and  we  use  tlie  same  terms  in  desei-ihiug  tlie  tubes. 

The  soft  ray  comes  from  a  "soft"  tube,  of  low  (comparative) 
vacuum;  these  rays  are  emitted  in  large  ({uantity,  have  a  consider- 
able chemical  action,  but  are  of  low  penetrating  power.  These  are 
the  rays  which  quickly  lead  to  dermatitis  if  permitted  to  act  too  long 
on  the  tissues.  They  produce  very  contrasty  Rontgenograins  of 
thin  parts. 

It  is  worse  than  useless  to  attempt  the  production  of  a  Rontgeno- 
gram  of  a  thick  part  with  a  soft  tube  by  unduly  prolonging  the 
exposure ;  this  simply  over-doses  the  tissues  with  rays  which  are  all 
absorbed,  and  the  only  result  will  be  a  "burn." 

The  hard  rays  come  from  a  "hard"  tube,  one  of  high  vacuum; 
they  are  emitted  in  relatively  less  ciuantity,  have  less  chemical 
action,  but  are  very  penetrating. 

The  medium  rays  come  in  large  quantity  from  a  tube  of  (com- 
parative) medium  vacuum,  and  are  best  for  general  purposes,  giv- 
ing good  bone-structure  and  contrast  between  bone  and  soft  tissue. 
For  bone  work  in  very  thick  parts  a  harder  ray  is  better.  If  too 
hard  a  tube  is  used,  the  extremely  penetrating  rays  being  so  little 
absorbed  by  the  bony  tissue,  give  a  flat  negative  without  contrast 
between  bone  and  soft  tissue. 

The  user  of  the  Rontgen  ray  should  be  very  careful  to  protect 
himself  from  its  deleterious  effects.  This  is  a  matter  of  the  utmost 
gravity ;  repeated  exposures  are  bound  to  produce  the  specific  results 
upon  the  tissues ;  the  Rontgen  ray  is  not  a  plaything.  A  serious 
dermatitis  results  invariably  in  carcinoma  with  a  strong  metastatic 
tendency,  and  the  death  roll  of  Rontgenologists,  with  several  yet 
living  whose  names  will  soon  be  added  to  it,  is  already  too  large. 

In  addition  to  the  fact  of  the  danger  to  life  from  incautious  ex- 
posure, is  the  fact  that  the  ray  affects  the  reproductive  organs  in 
such  a  way  as  to  produce  sterility  (not  impotentia). 

Fluoroscopes  are  now  provided  with  lead  glass  for  protection,  and 
opaque  gloves,  aprons,  gowns,  etc.,  may  be  procured.  There  are 
shields  of  heavy  lead  glass,  white  oxide  of  lead,  or  rubber  compound 
which  may  be  placed  directly  about  the  tube,  and  which  are  quite 
opaque  to  the  ray. 

In  estimating  the  time  of  exposure  for  different  parts,  one  should 
consider:  the  thickness  or  density  of  the  part;  the  distance  of  the 


746 


FRACTTTRES   AXD    DTST^OCATTOXR 


tubt';  the  penetrating  powcf.  oi-  liiirdiicssof  the  ray  used  ;  the  anionnt 
of  fUffi'iit  pasvsinw  tliroiiiili  llif  liilir;  tlic  kind  of  phite  nsed  (some 
are   imu-li   more  rapid   tluiii   olhci-si.     'IMic   use  of  an  intensifying 


Fig.   812. —  Kacliii-rhvdnomett'r. 


screen  ents  down  the  time  from  one-fifth  to  one-tenth,  bnt  it  also  cuts 
down  in  the  same  proportion  the  allowance  of  latitude  for  error  in 
calculation. 

There  are  scales  for   measuring  the   penetrating  power  of  the 


Pig.    813. — The  Bauer  qualiineter. 


ray;  the  best  of  these  is  the  Benoist  radio-chronometer  (Fig.  812)  ; 
with  this,  when  viewed  through  the  fluoroscope,  or  its  image  studied 
upon  the  plate,  a  comparison  is  made  of  the  color  produced  by  rays 


THE    USE   OP    THE   X-RAY 


747 


which  have  passed  through  pieces  of  aluminuTii  of  different  thiek- 
ness,  with  that  produced  by  rays  which  have  passed  through  a  piece 
of  silver  of  a  standard  thickness. 

The  hardness  of  the  rays  may  be  measured  by  means  of  the  Bauer 
Qualimeter,  a  sort  of  electro-static  torsion  balance  (Fig.  813). 

A  special  milliamperemeter  is  used  for  measuring  the  quantity 
of  high  voltage  current  passing  through  the  tube. 

Thus  quite  an  accurate  technique  may  be  built  up.  Experience 
soon  teaches  how  to  estimate  the  values  of  the  various  factors  so  that 
the  calculation  with  these  becomes  automatic  with  the  experienced 
operator. 

With  small  apparatus,  such  as  has  been  recommended  for  the 


Fig.    814. — Linear   fracture  of   upper   end  of   tibia. 

amateur  Rontgenologist,  it  is  necessary  to  make  rather  long  ex- 
posures in  order  to  produce  good  plates  of  the  thicker  parts ;  thus 
the  quiet  of  the  part  may  be  disturbed  by  respiratory  movements, 
or  muscular  twitchings  may  occur,  or  nervous  patients  may  find  it 
impossible  to  remain  quiet.  The  exposure  time  may  be  shortened  by 
the  use  of  intensifying  screens  as  has  already  been  said.  Such  a 
screen  consists  usually  of  a  sheet  of  cardboard  upon  which  has  been 
laid  a  smooth  coat  of  some  substance  which  fluoresces  when  exposed 
to  the  Rontgen  ray.  This  fluorescent  light  is  much  more  active 
actinically  than  is  the  Rontgen  ray  itself.  In  use,  the  chemical 
side  of  the  screen  is  placed  in  very  perfectly  intimate  contact  with 
the  film  of  the  plate    (a  special  plate-holder  is  necessary)  ;  this 


748 


FRACTURES   AND   DIST.OCATIONS 


jilato-lioldor  is  placed  under  tlie  part  to  be  examined,  preferably 
with  the  glass  side  of  the  ])late  toward  the  patient  and  tube;  the 
exposure  is  then  made,  and  \ery  much  shorter  llian  when  the  sereen 
is  not  used:  in  the  dark  room  the  holder  is  opened,  the  screen 
quiekly  removed  and  placed  in  its  container  and  the  plate  developed. 
Uidess  a  fine  sei'ecn  is  usi  d  and  great  cai'e  1;iken  that  the  exposure 


Fig.   815.  Fig.    816. 

Fig.    81.5. — .\ntero-posferim-  view  of  fracture  of  the  radius. 
Fis.    81(i. — Jjiitcral   view   of   sauie   case. 

ifs  ]ieither  too  long  nor  too  short  by  a  very  small  margin,  the  result 
will  not  be  satisfactory;  if  there  is  even  a  slight  overexposure  the 
image  will  be  ^'grainy"  and  the  lines  of  bone-structure  will  not  be 
shar])  and  clcai'.  The  t(M'lini('al  difficulties  are  multiplied  by  the 
screen,  but  its  use  will  he  of  value  wdien  examining  thick  parts  with 
small  apparatus. 

The  Rontgenogram  (Fig.  814)  produced  is  not  a  photograph;  it 


THE    USE   OP    TJJE   X-RAY 


749 


is  a  record  of  the  combined,  superimposed  images  of  the  various 
densities  contained  in  an  almost  infinite  number  of  planes  in  the 
object  examined,  through  which  the  ray  has  passed. 


Fig.    818. 


Fig.    817. — Fracture  of  the  femoral   sliaft  whicli  cannot  be  detected  because  the  ravs 
do   not  pass   through  the  plane   of   the   fracture. 

Fig.    818. — Another   plate  of   the   same  case.      No  evidence   of  fracture. 


A  single  view  of  a  fractured  bone  is  seldom  or  never  sufficient  for 
the  diagnosis;  exposures  should  be  made  from  at  least  two  points 
of  view,  generally  at  right  angles  to  each  other,  and  sometimes  more 


50 


KK'ACTIHKS    AM)    niSl.OCATIOXS 


aro  necessary  lo  I)!*!!!*;  out  ohsciirc  points,  since  the  IxrxMitprenofxi'nm 
is  in  a  wnv  a  sillinnette  oi'  slnulow  imaue. 


Fi 


FiK.   ^: 


Fig.  819. — .\nother  plate  of  the  case  shown  in  Figs.  817  and  818.  The  outlines 
seen  in  the  middle  of  the  shaft  miglit  lead  one  to  su.speft  fracture  hut  are  hardly  sufficient 
to  establish  a   diagnosis. 

Fig.  820. — Another  view  of  the  same  case  showing  tlic  fracture  ((uile  distinctly. 
This  plate  and  Figs.  817,  818  and  81'.!  demonstrate  the  possibility  of  overlooking  a 
fracture  if  the  case  is  examined  only   \n  one  plane. 

Fig.  815  shows  an  antero-i)Osterior  view  of  an  old  fracture  of  the 
radius;  the  lateral  view  shown  in  Fig.  816  demonstrates  very  strik- 
iiifflv  the  need  of  more  than  one  view. 


THE    TTSK    OF    THE    X-FIAY 


751 


Figs.  817,  818,  819  and  820  are  all  views  of  the  same  reiiiiir  fdiild  j 
taken  from  different  viewpoints. 

In  certain  parts  of  the  body  (the  shoidder,  for  example)  it  is 
impossible  to  obtain  two  views  at  right  angles  to  each  other;  here  the 
stereoscopic  method  is  of  special  importance.  In  this  method  two 
views  are  made  from  slightly  different  viewpoints,  bnt  bearing  a 
mathematical  relation  to  each  other.  For  the  first  view  the  target 
of  the  tube  is  placed  one  and  one-quarter  inches  to  one  side  of  a 
perpendicular  from  the  plate  passing  through  the  center  of  the 
object;  the  second  plate  is  made  after  moving  the  target  an  equal 


Fig.   821. 


Fig.   822. 


Figs.    821   and   822. — Stereoscopic   Rontgenogram  of   a  low  subcoracoid  dislocation   of 
the  shoulder. 

distance  to  the  other  side  of  the  perpendicular.  Stereoscopic  plates 
are  observed  by  means  of  a  plane  prism  stereoscope  (not  the  usual 
parlor  instrument),  and  a  perspective  view  results,  enabling  one  to 
get  all  the  relations  between  the  parts  of  the  image  (Figs.  821  and 
822,  subcoracoid  dislocation  of  humerus).  This  stereoscopic  view 
may  be  studied  by  means  of  a  trick  of  visual  accommodation  if  one 
has  not  a  stereoscope  handy ;  direct  the  gaze  to  a  point  midway  be- 
tween the  two  plates,  then  focus  upon  an  imaginary  oliject  some  dis- 
tance beyond ;  this  will  cause  the  appearance  of  three  images ;  study 
the  middle  one,  disregarding  the  two  outside. 

One  should  do  his  own  developing,  instead  of  referring  it  to  a 


752  FRACTURES   AND    11ISL(1CATI0NS 

pliotograi)lu'r ;  tlic  j)hotoy:i'a])h('r  may  Itc  a  better  teelniieian  at  tlio 
outset,  hut  he  is  rarely  sut^eieiitl>'  ac(|iiaiiite(l  with  anatomy  ami 
]iathology  so  that  he  will  know  at  what  stage  of  (leveU)])ment  to 
arrest  the  process. 

The  dark-room  must  a])solute]y  exelude  all  dayliglit  or  artilieial 
light  save  that  from  the  red  him]).  The  red  light  should  he  tested 
by  exposing  small  plates  to  it  and  de\-ehipiug  them,  in  order  to  make 
sure  it  is  a  "safe  light.''  If  possible  it  is  well  to  begin  the  develop- 
ment of  plate  in  total  darkness.  Put  the  plate,  lilm  up,  in  the  tray 
and  quickly  swirl  the  developer  over  it,  then  continuously  rock  the 
tray,  slowly  ;  hold  the  plate  up  to  the  red  light  after  a  time,  and  from 
time  to  time,  in  order  to  observe  the  progress  of  development,  but  do 
not  do  this  too  often,  no  matter  how  "safe"  the  light  is.  Develop 
until  by  reflected  red  light  the  back  of  the  plate  .shows  some  dark- 
ening, or  until  the  inuige  seen  by  red  light  transmitted  tlirongh  the 
plate,  begins  to  fade. 

A  good  developer  is  that  known  as  the  Cole  developer,  used  by 
Dr.  L.  Gregory  Cole  of  New  York : 

Distilled  water 32  ounces 

^Metol   40  grains 

Hydroquinone    6  drams 

Sodium  Sulphite    (dry) 2  ounces 

Sodium  Carbonate   fdry) 2  ounces 

Potass.   Bromide 40  to  60  grains 

A  fault  of  a  good  many  developers  recommended  for  Rontgen 
work  is  that  they  do  not  contain  enough  l)ronnde. 

The  temperature  of  the  develoi)er  should  not  be  above  sixty-five 
degrees  Fahrenheit.  After  development,  rinse  the  plate  carefully 
for  a  real  minute  in  running  water,  put  it  into  one  or  another  of 
the  hyposulphite  of  soda  fixing  solutions  in  order  to  dissolve  out  the 
unexposed  silver  salt  from  the  emulsion  ;  after  about  twenty  minutes, 
or  at  lea.st  ten  minutes  after  the  foggy  white  color  has  gone  from 
the  back  of  the  plate,  put  it  in  running  water  for  one  hour;  then 
take  out  and  set  on  edge  to  dry  in  a  room  of  even  temperature, 
where  dust  will  not  fall  upon  the  soft  emulsion. 

Be  cleanly  in  the  dark-room.  Have  trays  for  each  special  pur- 
pose, use  them  for  no  other,  and  keep  them  clean.  AVear  thin 
rubber  gloves  when  developing;  metol  is  veiy  poisonous  to  the  skin 
of  some  people.     Rinse  the  hands  carefully  every  time  they  have 


THE    USE   OF    THE   X-RAY  753 

been  near  a  solution.  If  a  very  little  hypo  is  carried  into  your 
developer  you  will  find  your  plates  displaying  some  very  peculiar 
appearances. 

Plates  which  are  not  quite  perfect  in  certain  respects  may  be 
improved  by  intensification  or  reduction,  as  indicated  by  the  quality 
of  the  density,  but  really  in  order  to  obtain  a  correct  plate  the 
exposure  must  have  been  very  nearly  correct  in  the  first  place  ;  after- 
manipulations  will  not  make  a  good  plate  out  of  a  bad  one. 

In  studying  plates,  put  them  in  a  window  against  a  clear  sky, 
north  light  preferred.  A  box  fronted  with  ground  glass  and  con- 
taining electric  lamps  is  a  convenience  as  it  may  be  used  at  any  time. 

Make  plenty  of  experimental  plates  of  normal  parts  in  order  to 
have  a  standard.  It  is  well,  in  injury  cases,  to  examine  the  corre- 
sponding normal  part  until  one  becomes  familiar  with  normal 
Rontgenologic  anatomy,  and  has  a  collection  of  normal  plates. 

There  are  no  "high  lights"  in  Rontgenograms ;  these  are  impor- 
tant in  camera  photography ;  the  corresponding  condition  in  a  Ront- 
genogram  is  the  black  part  of  the  plate  outside  the  field  of  the 
image ;  in  Rontgenography  we  are  dealing  with  what  photographers 
call  "shadow  detail." 

In  studying  plates,  look  out  for  the  appearances  (artefacts) 
caused  by  air  bubbles  adhering  to  the  plate  during  development, 
finger  marks,  scratches,  light-struck  spots  due  to  holes  in  the 
envelopes,  and  chemical  stain  and  fog. 

Look  out  for  confusing  lines  where  the  shadows  of  two  or  more 
bones  are  superimposed. 

Do  not  be  deceived  by  the  heavy  (white)  shadow  of  a  ridge 
for  muscular  attachment,  which  at  times  may  appear  to  be  the 
margin  of  a  fracture  shadow. 

Remember  that  epiphyses  unite  at  varying  periods  in  the  develop- 
ment of  the  individual. 

Do  not  mistake  a  normal  center  of  ossification  of  a  condyle  for  a 
displaced  fragment  of  bone. 

Remember  that  a  patient  may  have  more  than  one  fracture. 

Remember  that  a  fracture  may  be  located  at  some  distance  from 
the  seat  of  pain. 

Remember  that  a  functionally  perfect  result  may  appear  very 
far  from  being  an  anatomically  perfect  result. 

Just  because  your  plates  show  good  apposition  in  a  fracture 
located  near  a  joint,  do  not  be  over-optimistic  in  your  prognosis. 


CHAPTER  LIX. 

TTTE  OPEN  TREAT:\IENT  OF  FRACTURES. 

The  use  of  the  X-ray  and  operative  treatment  have,  of  recent 
years,  greatly  improved  the  results  in  certain  fractures  and  disloca- 
tions. Open  treatment  is  particularly  adai)ted  to  the  correction  of 
deformity  in  instances  in  whieh  simpler  methods  cannot  accomplish 
reduction  or  fail  in  preventino'  subsequent  displacement  during  the 
after-treatment.  Cases  in  which  operation  is  performed  may  be 
divided  into  two  groups:  the  first  includes  cases  in  whicli  this 
method  has  been  chosen  soon  after  the  injury  because  of  the  im- 
proved results  which  it  may  offer;  the  second  includes  cases  which 
are  operated  iipon  as  a  last  resort  after  non-operative  methods  have 
been  tried  and  proven  unsuccessful,  or  in  which  operation  was 
demanded  because  the  condition  was  compound  from  the  first.  The 
results  of  these  two  groups  of  cases  are  quite  different  and  should 
not  be  confounded  when  deliberating  upon  the  advantages  of  opera- 
tive treatment.  Consideration  at  this  time  is  only  given  to  cases  in 
Avhicli  operation  is  performed  as  an  initial  measure  because  it  offers 
better  results  than  non-operative  procedures.  Operation  done  in 
compound  fractures  will  be  taken  up  under  the  headings  of  "Treat- 
ment of  Compound  Fractures  and  Dislocations,"  page  789. 

All  forms  of  treatment  give  a  higher  proportion  of  functionally 
perfect  results  in  children,  and  hence  the  difference  between  opera- 
tive and  non-operative  results  is  less  marked  before  puberty.  With 
advancing  years  the  proportion  of  eases  in  which  a  better  result  can 
be  obtained  by  operation  increases.  Mechanical  means  for  the 
direct  or  internal  fixation  of  the  fragments  have  been  known  and 
employed  for  many  years,  but  it  is  only  recently  that  improved 
technique,  both  as  to  appliance  and  asepsis,  have  demonstrated  the 
real  value  of  the  operative  method.  Wire,  nails,  screws,  pegs, 
clamps,  ferrules,  and  absorbable  suture  materials,  have  all  been 
used,  and  even  now  have  their  appropriate  places.  But  the  develop- 
ment of  the  Lane  plate  has  proven,  undoubtedly,  the  greatest  stride 
in  the  open  treatment  of  fractures.     It  is  a  well  known  fact  that 

754 


THE   OPEN    TREATMENT   OF    FRACTURES  755 

perfect  anatomic  reduction  is  not  always  essential  to  the  complete 
restoration  of  function,  yet  the  more  cases  in  which  absolutely  exact 
reduction  is  obtained,  the  greater  will  be  the  dec^reasc  in  the  per- 
centage of  cases  showing  loss  of  function.  We  shouh],  tli(;rci'ore, 
endeavor  in  each  and  every  case  to  secure  as  accurate  an  anatomic 
result  as  is  possible.  Proper  operative  treatment  not  only  accom- 
plishes more  perfect  apposition  and  fixation  of  the  fragments  hut 
shortens  the  period  of  disability,  gives  better  functional  results  and 
lessens  the  suffering  of  the  patient.  Probably  the  best  time  for 
operation  is  from  seven  to  ten  days  following  the  accident.  This 
allows  the  tissues  to  recover  from  the  initial  shock  and  gives  time 
for  the  development  of  local  resistance.  In  operating  on  simple 
fractures  the  surgeon  should  fully  appreciate  that  he  is  rendering 
the  condition  compound,  and  that  infection  following  open  treat- 
ment is  often  productive  of  much  worse  results  than  would  be  the 
case  if  surgical  measures  had  not  been  instituted.  For  this  reason 
the  most  strictly  aseptic  surroundings  are  demanded  and  the  oper- 
ator should  be  skilled  in  this  particular  branch  of  surgery.  Those 
unaccustomed  to  bone  work  should  not  attempt  these  cases.  The 
surgeon  should  possess  a  mechanical  sense  peculiar  to  this  particular 
type  of  work,  and  an  appreciation  of  the  relative  strengths  of  the 
materials  operated  upon  and  employed.  This  mechanical  sense, 
referred  to,  is  easier  to  illustrate  than  to  define.  For  example :  if 
we  observe  an  experienced  mechanic  at  work,  we  never  see  him 
tighten  a  nut  until  the  threads  strip  or  the  shaft  of  the  bolt  twists  in 
two,  and  yet  he  tightens  nuts  of  all  sizes  and  threads,  each  one 
requiring  a  different  degree  of  force  to  properly  seat  it.  In  like 
manner  the  expert  cabinet  maker  saws  and  shapes  his  wood  to  fit 
the  desired  places  and  yet  a  nail  is  never  driven  without  due  consid- 
eration for  the  strength  and  nature  of  the  material  through  which 
it  passes  and  the  function  which  it  is  to  perform,  nor  is  a  screw 
driven  home  so  that  the  last  turn  strips  the  thread,  breaks  the  shaft 
or  causes  the  wood  to  split.  On  the  other  hand,  if  we  watch  the 
apprentice  learning  his  trade,  the  lack  of  mechanical  sense  is  ap- 
parent in  the  frequency  with  which  he  spoils  materials  and  ruins 
his  tools. 

Any  one  who  has  seen  the  last  screw  of  a  Lane  plate  split  the 
shaft  of  a  bone,  or  a  bone  graft  broken  just  as  it  is  being  brought 
into  position  will  appreciate  the  value  of  this  mechanical  sense  and 
see  what  can  be  learned  by  the  surgeon  from  the  artisan.     One 


756  FRACTURES   AND   DISLOCATIONS 

desirous  of  inereasino:  liis  ])rofi('ien('y  in  this  particular  branch  of 
surgery  shoukl  obtain  fresh  bones  from  the  Ijutclicr  and  then  with 
chisel,  saw,  nail  and  screw  determine  to  his  own  ])ractical  satisfac- 
tion the  relative  strentrth  of  bone,  and  just  what  it  will,  and  will  not 
stand.  Later  on  fresh  specimens  from  the  dissecting  room  siiould  be 
procured  and  the  same  experiments  conducted.  In  addition  the 
various  t^'pes  of  fixation  may  be  tried  out  on  difVerent  portions  of 
the  bone  and  the  security  of  the  fixation  tested.  The  difference 
between  cancellous  and  compact  tissue  may  be  appreciated  in  this 
way  and  in  no  other,  outside  the  operating  room.  When  this 
experience  has  been  gained  further  obstacles  to  progress  ma}-  be 
minimized  by  assisting  or  observing  some  surgeon  of  experience 
in  bone  work,  until  a  satisfactory  technique  is  obtained. 

The  question  of  when,  and  when  not  to  operate  in  a  given  case 
depends  upon  the  general  condition  of  the  patient  and  the  degree  of 
reduction  which  is  pos.sible  by  non-operative  methods.  Diseased 
states,  such  as  diabetes,  erysipelas,  advanced  nephritis,  etc.,  otfer 
contraindications  to  operation,  in  the  open  treatment  of  fractures, 
the  same  as  they  do  in  other  fields  of  surgery.  If  the  general 
health  of  the  patient  allows  of  an  operation,  the  question  then 
arises:  "Can  an  equally  good  result  be  obtained  by  the  non- 
operative  method  as  is  possible  with  open  treatment  ? ' '  and  secondly, 
"Are  the  proper  surgical  surroundings  and  skill  available?" 

In  conclusion,  then,  we  might  state  that  with  the  proper  health  of 
the  patient  and  available  surgical  facilities,  all  cases  of  fracture 
should  be  operated,  in  which  an  equally  good  result  cannot  other- 
wise be  expected. 

The  site  of  the  operation  should  be  carefully  shaved,  and  painted 
with  a  three  and  a  half  percent  solution  of  iodine  (half  strength  tr. 
iodi)  the  day  preceding  the  operation.  The  i)arts  are  then  covered 
with  sterile  dressings  until  the  time  of  operation.  The  parts  are 
again  painted  wdth  tincture  of  iodine  (five  percent)  before  the 
incision  is  made.  As  soon  as  the  skin  is  divided  the  cutaneous  edges 
should  be  covered  with  gauze  or  towels  which  are  secured  in  position 
by  small  tenacula2,  thus  preventing  infection  of  the  deeper  struc- 
tures from  the  cut  edges  of  the  skin.  Ivul)ber  gloves  are  demanded, 
the  hands  should  be  kept  out  of  the  wound,  as  far  as  possible,  and 
instruments  having  come  in  contact  with  the  gloves  should  not  enter 
the  wound.  In  other  words,  the  most  strict  aseptic  precautions 
should  be  observed  in  every  detail,  gloves  should  be  worn  and  then. 


THE   OPEN    TREATMENT   OP    FRACTURES  757 

while  operating,  the  surgeon  slionld  consider  his  gloved  hands 
capable  of  infecting  the  wound.  The  danger  in  tliis  particular  work 
lies  largely  in  the  fact  that  a  glove  may  be  torn  b\'  one  of  the  serrated 
fragments  while  attempting  reduction,  and  when  this  occurs  the 
pent-up  perspiration  from  the  hand  is  poured  out  into  the  wound. 
A  pin-hole  in  the  glove  may  cause  leakage  onto  the  field  of  operation 
during  the  entire  procedure. 

The  details  of  the  operation  and  the  exact  form  of  internal  fixa- 
tion which  will  best  meet  the  requirements  of  the  case  in  hand  are 
often  only  determined  after  the  bone  has  been  exposed.  The  exact 
nature  of  the  fracture,  with  the  fragments  exposed,  frequently 
appears  different  from  the  conditions  anticipated,  even  though  care- 
ful examination  has  been  previously  made  and  the  X-ray  employed. 
The  surgeon  should,  therefore,  have  a  number  of  appliances  ready 
that  he  may  choose  from  among  them  to  more  perfectly  meet  the 
requirements  of  the  conditions  encountered.  If  an  internal  fixation 
appliance  is  employed  it  should  secure  the  fragments  as  solidly  as 
may  be,  even  to  the  extent  of  sustaining  the  weight  of  the  extremity. 
In  the  subsequent  treatment,  however,  splints  should  be  employed  in 
such  a  manner  as  to  relieve  the  internal  fixation  appliance  from 
as  much  strain  as  possible.  In  other  words,  internal  fixation  should 
never  be  called  upon  to  do  the  work  of  splints  or  other  forms  of 
external  fixation.  The  fact  that  internal  fixation  is  so  often  used 
in  the  open  treatment  of  fractures  does  not  necessarily  indicate  that 
the  objects  of  operation  may  not  sometimes  be  attained  without  its 
employment.  In  some  instances  accurate  engagement  of  the  ser- 
rated ends  of  the  fragments  during  operation,  will  be  sufficient  to 
prevent  lateral  or  overriding  deformity,  and  the  proper  application 
of  appropriate  splints  may  be  relied  upon  to  prevent  angular  dis- 
placement. Reduction  of  deformity  and  fixation  are  thus  obtained 
by  operation,  but  without  the  use  of  any  type  of  internal  or  direct 
fixation. 

It  is  essential  that  the  anatomy  of  the  parts  operated  upon  be 
understood  so  that  important  structures,  such  as  nerves  and  vessels, 
may  be  avoided  and  the  displacing  action  of  the  muscles  attached  to 
the  fragments  may  be  appreciated.  The  internal  structure  of  the 
bone  should  be  understood  as  well  as  its  surface  form,  since  so  much 
depends  on  the  nature  of  the  portion  of  the  bone  operated. 

Irrigation  of  the  wound,  just  before  closure,  with  a  gallon  or  so  of 
hot  sterile  physiological  salt  solution  will  promote  hemostasis  and 


758 


FKACTrUKS    AND    DISLOCATIONS 


tend  to  remove  any  infection  wliicli  nii«>;ht  liave  gained  entrance 
(lnrini>:  tlie  ojxTation.  The  nse  of  the  so-called  antiseptic  solutions 
within  the  w.ound  are  not  only  useless,  hut  tend  1o  daiiiaii'e  the 
tissues.  .When  possible  a  ruiunnij:  suture  of  catgut  shoidd  approxi- 
mate tlie  muscles  before  the  skin  is  closed.  Deep  through  and 
through  sutures  are  most  objectionable.  The  large  majority  of 
operations  done  on  fractures  jniss  through  heavy  nniscidar  tissue 
which  is  highly  vascular.  Extravasation  of  blood  into  the  wound 
is  almost  sure  to  follow,  even  though  hemostasis  seems  perfect  at 
the  time  of  closure.  Living  blood  within  the  vessels  possesses 
distinct  bactericidal  activity,  but  wiien  extravasated  this  quality 
soon  disappears,  the  result  being  that  collections  of  dead  blood 
within  a  wound  act  as  most  excellent  culture  media,  at  body  tem- 
perature, thus  favoring  subsequent  suppuration.  It  is  evident, 
therefore,  that  fluids  forming  within  the  wound  following  closure 
should  be  allowed  to  escape  at  the  earliest  possible  moment.  If  a 
few  strands  of  silkworm-gut  be  so  placed  within  the  wound  that 
they  act  as  drains,  this  most  important  requisite  will  have  been  ful- 
filled. The  field  of  operation  .should  be  inspected  within  twenty- 
four  or  forty-eight  hours  and  gentle  pressure  exerted  in  such  a 
manner  that  any  fluids  which  may  have  collected  in  the  meantime 
will  be  expressed. 


c^ii!i^g>       ic^Biii^ji       ic^Enai^ 

823. — Jh'thdds   of    usiiiic   win-   in    tlu-   intornal   ti.Niition    of   friuUirt 


The  Use  of  Wire  has  been  largely  supplanted  by  the  Lane  plate, 
though  it  still  i-etains  its  i)lace  of  ])reference  in  certain  fractures, 
notably  those  of  the  olecranon  and  patella,  and  in  some  cases  of 
fractures  in  the  extremities  of  the  long  bones.  The  difit'erent  ways 
in  which  wire  may  be  used  are  shown  in  the  accompanying  plates 
(Fig.  828).  In  fractures  near  the  expanded  extremities  of  the 
long  bones  a  single  looj)  of  wire  properly  i)laced  may  be  sufficient 
to  prevent  displacement    (see  Fig.  825).     In  wiring  the  shafts  of 


THE    Oi'EN    TREATMENT   OF   FltACTUKES 


759 


the  long  bones  it  is  almost  essential  that  two  points  of  fixation 
be  employed  to  secure  proper  leverage  (see  Fig.  638).  The 
circular  wire  has  the  advantage  of  not  entering  the  medullary 
cavity,  and  of  not  requiring  the  destruction  of  bone  tissue  l)y 
drilling.  In  most  instances  the  firmest  hold  is  obtained  by  having 
the  wire  pass  perpendicularly  through  the  plane  of  fracture 
whether  spiral,  oblique  or  transverse.  If  the  fracture  approaches 
the  transverse  type  or  the  serrations  are  coarse  enough  to  permit 
of  firm  engagement  a  single  loop  of  wire  may  be  sufficient  to 
prevent  lateral  displacement,  angular  deformity  being  prevented 
by  the  proper  use  of  splints. 


Figs.    824   and   825. — -An  examiDle  of   how  a  single  loop   of  wire  can  be  made  to  hold 
the  end  of  a  bone  in  position. 

The  essentials  in  the  use  of  wire  are  firstly,  that  the  material 
be  heavy  enough  to  withstand  the  strain  to  which  it  is  subjected, 
and  secondly,  that  it  be  firmly  placed  and  secure  proper  leverage 
on  the  fragments.  These  points  are  best  appreciated  by  referring 
to  the  accompanying  diagrams.  Heavy  wire  is  as  well  tolerated 
by  the  tissues  as  if  the  material  used  were  light  and  inadequate. 
Virgin  silver  wire  has  for  years  been  considered  the  best,  but 
recently  bronze-aluminum  wire  has  been  preferred  by  many,  be- 
cause of  its  greater  torsion  strength. 

Nails,  Pegs,  Screws  and  Staples  have  all  been  used  to  secure  the 
fragments  in  position,  but  at  the  present  time  the  development  of 


760 


FRACTURES   AND   DISLOCATIONS 


more  perfect  ajipliances  lias  rendered  tlieir  use  more  limited.  They 
are  ouly  now  employed  i"or  the  ])urpos('  of  securino:  a  small,  dis- 
placed fragment  such   as  a    fcactin'cd   coiKlylc   luhcrclc  or  tuber- 


Fig.  826. — Iiistninionts  ^\lli(•ll  h;ive  liccn  for  ml  of  considci-jilik'  service  in  operating 
on  fractures.  On  the  left  is  shown  ;i  lion-.iawecl  bone  f()r(ei)s  with  ratchet  in  the  handle. 
By  means  of  this  instrument  it  is  often  ijossible  to  liold  the  frasnients  in  reduction 
while  applying  internal  fixation  apparatus.  The  instruments  to  the  right  are  ordinary 
retractors  with  the  handle  ends  shaped  and  drill(Hl  so  tliat  they  ma.v  he  used  in  passing 
wire  about  the  shafts  of  long  bones. 

osity.     A  good  example  of  the  appropriate  use  of  a  nail  is  shown 
in  Fiof.  219.     In  this  case  the  external  condvli^  of  the  huinerns  was 


Fig.   827. — The   linne   bone   drill. 


broken  off  and  so  displaced  that  the  elbow  would  have  remained 
useless  if  operation  had  not  been  performed.  The  nail  has  been 
driven  at  right  angles  to  the  displacing  pull  of  "the  muscles  attached 


THE   OPEN    TREATMENT   OP   FRACTURES 


761 


to  the  fragment,  and  in  this  position  securely  holds  the  condyle 
against  the  recurrence  of  deformity.  In  the  use  of  nails  the  hole 
drilled  in  the  bone  should  be  only  a  trifle  smaller  than  the  size  of 
the  nail  to  be  used,  otherwise  the  bone  may  be  split  when  the  nail 
is  driven  home.  The  same  holds  true  in  the  use  of  screws,  pegs 
and  staples. 

Screws  and  nails  have  been  used  with  some  success  in  the  treat- 
ment of  fractures  of  the  femoral  neck,   the  nail   or  screw  being 


Pis.    828. — Bone  forceps. 


driven  through  the  great  trochanter  to  enter  the  neck  parallel  to 
its  long  axis.  The  reason  that  success  has  not  been  more  constant 
in  operating  on  this  portion  of  the  femur  is  because  of  the  soft, 
cancellous  tissue  of  which  the  internal  structure  of  the  upper  end 
of  the  femur  is  composed.  Screws,  nails  and  pegs  depend  for 
their  hold  mainly  on  compact  tissue,  and  in  regions  of  the  skeleton 
in  which  cancellated  structure  predominates,  little  reliance  can  be 
placed  upon  them  if  the  displacing  action  is  considerable.  Thus 
when  a  nail  is  driven  into  the  extremitv  of  one  of  the  long  bones  it 


762 


FRACTURES   AND   DISLOCATIONS 


will  usually  be  found  possible  to  tear  it  out  witb  the  fingers;  but 
if  the  shaft  is  selected  as  the  site  of  the  cxixM-iniont  the  nail  will 
be  found  as  solidly  seated  as  it'  (lii\rn  into  wood.  This  dilt'erenee 
is  entirely  dependent  upon  the  (lis[)ositiou  of  the  compact  tissue, 
and  it  is  evident,  therefore,  tiiat  before  a  surgeon  operates  on  a 
given  region  he  should  be  acquainted  with  the  internal  structure 
as  wt'll  as  the  surface  form  of  tlu'  jiortion  of  the  bone  fractured.  If 
a  luiil  Of  screw  once  gives  in  cancellous  tissue  tlie  seeuritv  of  tixa- 


Fig.  830. — Gerster's  turn-lnu-kles  fur  reducing  diflicult  fractures,  e.specially  of  the 
long,  large  bones  sucli  as  the  femur  and  lunnerus.  They  may  be  u.sed  to  advantage  in 
some  cases  though  it  is  seldom  that  proper  angulation  of  the  fragments  and  manipulation 
fail  in  accomplishing  reduction  in  the  open  method.  Great  force  can  be  e.\erted  bv  this 
mechanism   and   it  should   not   be   used   witliout   due   regard   for   the   damage   it   may    inflict. 


tion  is  lost,  but  on  the  other  hand  a  loop  of  wire  never  releases  the 
fragments  until  entirely  torn  out  even  though  some  displacement 
may  occur.  Screws,  like  nails,  depend  on  the  compact  tissue  for 
their  hold,  and  it  is  apparent  that  tlieir  value  decreases  as  the 
epiphyses  are  approached.  The  thread  of  any  screw  used  in  bone 
work  should  continue  to  the  head  and  the  screw  itself  should  be  of 
the  type  used  in  woodwork.  Sherman  has  devised  a  screw  of  the 
machine  type  with  a  shaft  of  uniform  thickness  throughout.  The 
end  of  the  screw  is  made  like  a  tap  so  that  it  cuts  its  own  thread  as 


THE   OPEN    TREATMENT   OP   FRACTURES 


763 


it  sinks  into  the  bone.  Tlie  ])i-iiicipl(;  is  good  and  the  screw  should 
be  efficient,  though  the  author  lias  had  no  cxi)erience  with  it. 
"When  a  screw  is  driven  home  it  should  not  be  too  tightly  fixed  lest 
it  strip  the  threads  cut  in  the  bone  or  cause  the  subsequent  absorp- 
tion of  compact  tissue  through  too  great  stress.  Ivory  pegs  are 
practically  unused  at  the  present  time.  Nails  and  screws  should 
be  made  of  steel  and  either  nickel  or  silver  plated. 


Fig.   831. — Appliance  for  holding  plate  in  position  while  screws  are  being 
also  holds  fracture  in  reduction. 


placed.     It 


The  Four-post  Clamp. — Numerous  modifications  of  the  four-post 
clamp  have  been  devised  and  used  with  more  or  less  success  though 
they  have  been  almost  entirely  superseded,  in  the  last  few  years,  by 
the  Lane  plate.  Notable  among  the  variations  of  the  four-post 
clamp  is  the  one  devised  by  Parkhill  in  which  the  fragments  are 
held  in  alignment  by  four  long,  threaded,  steel  rods.  These  rods 
are  screwed  into  drill  holes,  two  on  either  side  of  the  fracture,  and 
held  together  at  their  superficial  ends  by  a  special  locking  device 
(see  Figs.  832  and  833).  The  four  posts  must  be  in  the  same  plane 
and  parallel  to  each  other  in  order  that  this  particular  locking 
device  may  securely  hold  them ;  it  will  readily  be  seen  that  this 
type  of  appliance  is  difficult  of  application. 

Some  other  modifications  of  the  four-post  clamp  do  not  require 
that  all  the  posts  should  be  parallel,  although  it  is  necessary  in  all 
types  that  they  be  in  the  same  plane.  Excellent  results  have  been 
secured  by  using  the  four-post  clamp,  and  it  will  be  found  at  the 


76i 


FRACTURES   AND   DISLOCATIONS 


present  time  the  most  sntisfaetoi-y  method,  next  to  the  Lane  plate, 
of  securing  some  forms  of  fracture.  If  the  mechanics  of  the  clamp 
be  studied,  and  compared  ^vith  the  ])late,  its  inferiority  will  be 
apparent.  In  tracing  the  fixation  through  the  clamp  from  one 
fragment  to  the  other  it  will  be  seen  that  there  are  twice  as  many 
points  of  possible  motion  as  compared  with  the  plate.     Thus  a  four- 


Fig.    s:',i'. — Slu.ws    a    ((iniijdiincl    fviwture    (if    tiliia    and    lilmla.      Noti'    limv    \Ur  iiiippr 

end    of    both    luwer    l■l•asm^.-llt^s    project    tUrout;h    tlu>    sUiu.      Thv    anulc    at    wiiiili    tlic  li-g    is 

held   shows    the    flail-like    condition.      Picture    tiikon    a    few    liours    followintc    injury.  Case 
seen  with  Drs.   Lyman   and  Thompson. 


Fig.    833. — Same  case  as  showji   in   Fiii.  ^^i-   after  ieductioji  and  securing  of  the  frag- 
ments by  means  of  Freeman's  modification  of  the  four-jiost   clamp. 

post  clamp  has  eight  points  of  possible  motion,  whereas  a  four-screw 
plate  has  only  four.  In  addition  to  this  the  four-post  clamp  is  at 
a  disadvantage  because  of  the  distance  of  the  locking  device  from 
the  bone,  which  means  so  much  leverage  against  fixation.  Besides 
the  mechanical  inferiority  of  the  four-post  clamp,  it  will  be  ob- 
served that  four  tracts  must  be  left  open  from  the  bone  to  the  skin 
when  the  posts  are  in  position,  which  can  only  mean  increased  risk 


THE   OPEN    TREATMENT   OP   FRACTURES 


765 


of  infection  during  the  after-treatment.  It  has  been  claimed  by 
some  that  the  four-post  clamp  possesses  a  distinct  advantage  in 
that  no  foreign  body  is  ultimately  left  within  the  tissues.  This 
argument  may  seem  sound  theoretically,  but  practice  has  proven 


rig.    834. — Set   of    Sherman's   modification   of   Lane's   plate   manufactured   by   Harvey 
Pierce  &  Co.  of  Philadelphia.      Made  of  Vanadium  steel. 

beyond  a  doubt  that  certain  foreign  materials  properly  placed 
within  the  tissues  are  tolerated  without  the  slightest  disturbances. 
In  the  presence  of  infection  all  appliances  are  alike  failures, 
whether  four-post  clamp,  plate,  nail,  screw  or  wire.  It  will  readily 
be  seen,  therefox^e,  that  the  difi&culty  of  application,  mechanical  in- 


766 


FRACTURES   AND    DISLOCATIONS 


feriority  and  increased  risk  of  iiifcclion  I'ciidcr  tlie  four-post  clamp 
a  inncli  nioi-c  imperfeet  api)li;iiii-i'  tlian  is  llic  Lane  plalc. 

The  Lane  Plate. — -Lane's  mctliod  ol'  intmial  lixalion  oL'  the  frag- 
ments is  aceomi)lislied  I)\  iiifaiis  of  cold-rolled  steel  plates  and 
screws  as  shown  in  Fig'.  S'.'A.     Tlic  most   I'iuid  asepsis  is  observed 


Fig.   835. — Comparison  of  the  wood  screw  ordinarily  used  with  the  Lane  plate,   and 
Sherman's  "tap-screw."      (After  Sherman  in  Surg.,  Gynecol.  <6  Obstet.) 


Screwdriver;  special  construction  to  fit  tap  screws. 
Center  point  fixes  screw  and  insures  vertical  and  direct 
driving. 


3/8  IN. 


5/q  in. 


Vanadium  steel  self-tapping  (fluted)  screws.  Three 
flutes  are  provided  at  end  of  each  screw,  thus  combininf 
a  tap  and  screw. 

Fig.    8:!6. —  (.\fter    Sherniiin    in    Surf/.,    Gynecol.    (£•    Obstet.) 


during  the  entire  procedure.  As  soon  as  the  incision  is  made,  the 
skin  edges  are  protected  and  other  precautions  taken  to  prevent 
infection  as  previously  described  on  page  756.  ^Fhe  incision  is 
carried  down  to  the  bone  and  the  fragments  exposed,  brought  back 
into  alignment  and  held  in  apposition  b}^  means  of  a  heavy  clamp 
of  special  design.     A  plate  of  appropriate  size  is  then  placed  and 


THE    OPEN    TREATMENT    OF    FRACTURES 


767 


held  against  the  bone  by  the  ehitrip.  Holes,  slightly  smaller  than 
the  screws  to  be  used,  are  drilled  in  the;  botu;  eorresponrling  in 
position  to  the   openings   in    tlu;    plate.     Scr'cws    arc    then    (lfi\c>i 


Fig.  837. — Examples  of  broken  Lane  plates  of  the  ordinary  type.  Note  the  point 
at  which  the  break  usually  takes  place,  (xiftor  Sherman  in  Surg.,  Gynecol,  d  Obstet., 
June,   1912.) 


Fig.   838. 


Fie.    840. 


Fig.  838. — A.  P.  view  of  fracture  of  both  bones  of  leg. 

Fig.  839. — Lateral  view  of  same   case. 

Fig.  840. — ^Same  case  two  years  later. 

Fig.  841. — Another  view  of  same  case  at  time  Fig.  840  was  taken. 


home,  securing  the  plate  to  the  bone  which  in  turn  immobilizes  the 
fragments.  The  deep  structures  are  then  approximated  by  catgut 
and  the  skin  incisiori  is  closed.     Drainage  by  means  of  silkworm- 


768  FKACTLKES   AND   DISLOCATIONS 

gut  should  1)0  establislied  for  the  first  twenty-four  or  forty-eight 
hours  to  allow  the  escape  of  fluids  which  may  eoUect  within  the 
wound.  The  plate  should  be  accurately  shaped  to  the  surface  of 
the  bone  before  being  screwed  into  position.  It  should  be  so  bent 
as  to  come  in  contact  with  the  bone  througliout  its  entire  extent 
witliout  special  stress  at  any  given  point.  If  the  plate  lias  been 
securely  fixed  and  the  pro})er  aseptic  precautions  observed  through- 
out the  operation,  it  will  remain  in  position  indeHnitely  witliout 
giving  rise  to  trouble.  In  the  cxtreiiiitics  of  the  long  bones  the 
plate  is  not  as  efficient  because  of  the  thinness  of  the  compact  tissue 
on  which  the  screws  depend  for  their  holds.  A  simple  wire  loop, 
properly  placed,  will  often  hold  the  fi-acturt'd  extremity  of  one  of 
the  long  bones  in  i)Osition  more  securely  than  the  plate.  The  Lane 
plate  should  never  cross  an  ei;)iphyseal  cartilage  because  of  the 
possibility  of  disturbing  the  subsequent  gi-owth  of  the  bone.  A 
screw  should  never  be  placed  closer  than  one-fourth  of  an  inch 
from  the  end  of  a  fragment ;  the  nearer  the  screws  are  placed  to 
the  line  of  fracture  the  greater  the  danger  of  splitting  tlie  bone. 
Plates  of  various  sizes,  shapes  and  weights  have  been  designed  by 
Lane  to  meet  the  rec(uirements  in  different  portions  of  the  skeleton 
and  may  be  secured  from  the  instrument  dealer. 

Absorbable  Suture  Material  is  employed  and  strongly  advocated 
by  some  surgeons  for  certain  fractures  in  which  the  displacing 
strain  is  not  pronounced.  Excellent  results  have  followed  its  use 
in  many  cases,  in  other  instances,  however,  the  nature  of  the 
material  has  been  responsible  for  a  repetition  of  the  operation 
because  of  the  recurrence  of  deformity.  The  nature  of  tlie  fixation 
required  is  so  different  from  that  to  be  fulfilled  in  the  approxima- 
tion of  soft  tissues  that  one  should  not  employ  absorbable  material 
lightly  and  without  due  consideration  for  its  shortcomings  as  well 
as  its  one  advantage  of  being  absorbable.  It  should  be  remembered 
that  the  most  important  time  for  fixation  does  not  commence  until 
eight  or  ten  days  after  the  operation  when  the  bony  callus  begins 
to  form.  It  is  just  about  this  time  that  absorbable  material  is 
beginning  to  lose  its  strength,  and  if  it  releases  its  hold  within  the 
first  two  or  three  weeks  another  operation  may  be  necessary.  The 
edges  of  the  drill  holes  may  cut  the  suture  material  before  the 
callus   is    sufficiently   strong   to   hold    the    fragments    in    position. 

The  so-called  "ten  day"  and  "twenty  day"  chromicized  catgut 
does  not  always  correspond  to  the  label,  in  the  time  which  it  takes 


THE  OPEN  TREATMENT  OF  FRACTURES 


769 


for  the  material  to  be  removed  by  absorption.  Ten  to  twenty  days 
is  more  than  ample  for  the  processes  of  healing  in  soft  tissues 
under  aseptic  conditions.  Bone,  however,  requires  a  longer  period 
in  which  to  unite.     If  the  suture  material  becomes  soft  and  lax 


Fig.  842. — Tibia  from  which  Lane  plate  has  heen  removed  because  of  infection. 
Non-union  present  in  spite  of  heavy  callus  seen  in  plate.  Note  the  absorption  of 
bone  where  the  screws  were  placed. 


within  a  week  or  two,  motion  may  occur  between  the  fragments  and 
delayed  or  non-union  may  follow.  The  surgeon,  in  the  meantime, 
is  laboring  under  the  false  impression  that  the  fragments  were 
securely  and  permanently  fixed  at  the  time  of  operation.     In  addi- 


770  FRACTURES   AND   Dlf^LUCATIONS 

tion  it  uuiiht  he  stated  tliat  chromie  ^iit  is  not  as  easy  of  steriliza- 
tion as  are  niotallic  .sn])staiu'es,  siieli  as  wire,  and  the  Lane  plate. 
Absorbable  suliii'c  in.itcriiil  is  more  coimiionl)-  used  in  repair  of  the 
]iatella  and  olecranon  tlian  in  other  rcfjcioiis.  Tlie  purpose  is  accom- 
plislh'd  in  either  of  these  two  parts  hy  suturing  the  torn  fasciae 
attached  to  the  fragments  rathei-  than  hy  direct  suture  of  the  bone. 

In  conclusion  it  might  be  stated  that  absorbable  suture  has  the 
advantage  of  being  entirely  removed  after  it  has  accomplished  its 
purjiose,  but  it  is  so  insecure  that  it  had  better  be  discarded,  in 
most  cases,  in  favor  of  some  metallic,  mechanical  material. 

The  subject  of  tlie  ojjcn  treatment  of  fractures  cannot  be  con- 
sidered com])h'tt'  without  cntci-ing  into  the  uses  and  indications  of 
bone  transi>lan1ati()ii.  It  is  not  improbable  that  many  of  the  estab- 
lisiied  methods  in  opei'ating  on  fractures  will,  in  the  near  future, 
be  revised  or  e\'eii  discarded  when  the  possibilities  and  uses  of 
bone  grafting  become  better  known  and  further  developed.  Bone 
transplantation  will  be  taken  up  in  the  following  chapter. 


CHAPTER  LX. 

BONE  TRANSPLANTATION. 

One  of  the  most  important  developments  of  surgery  in  recent 
years  is  the  transplantation  of  bone  to  fill  in  deficiencies  in  the 
skeleton  which  have  resulted  from  injury  or  disease.  As  a  sur- 
gical procedure  it  has  become  well  established  in  spite  of  the  fact 
that  the  fundamental  underlying  principles  are  as  yet  by  no  means 
established.  The  three  theories  which  have  had  the  greatest  fol- 
lowing are  those  of  Axhausen,  Macewen  and  Murphy,  and  the  very 
diversity  of  these  theories  points  unmistakably  to  the  fact  that  the 
subject  has  yet  to  be  explored  and  the  actual  facts  determined. 
'Axhausen  maintains  that  the  bone  composing  the  graft  invariably 
dies,  and  is  absorbed  and  replaced  by  new  bone  formed  from  the 
periosteum  surrounding  the  transplant.  According  to  this  theory 
the  periosteum  is  all  that  remains  of  the  original  transplant,  and 
the  success  of  the  operation  depends  entirely  on  this  membrane. 

Macewen  of  Glasgow  is  of  the  opinion  that  the  graft  is  repro- 
duced entirely  from  the  osteoblasts  within  the  transplant,  and  that 
the  periosteum  has  nothing  to  do  with  regeneration  of  bone,  but 
acts  only  as  a  limiting  membrane  preventing  the  osteoblasts  from 
penetrating  the  surrounding  tissue. 

Murphy  of  Chicago  states  that  the  graft  acts  only  as  a  scaffold- 
ing for  the  production  of  new  bone  by  the  osteogenetic  elements 
which  pass  from  the  living  bone  into  the  transplant  at  the  points 
of  contact.  In  other  words,  he  maintains  that  the  graft  is  not 
osteogenetic  but  only  osteoconductive,  and  that  therefore  the  solid 
contacting  of  the  graft  with  living  bone  is  the  important  point, 
and  not  the  activity  of  the  periosteum.  It  is  probable  that  each 
of  these  theories  contains  some  truth  but  that  no  one  of  them  is 
entirely  correct.  Since  the  setting  forth  of  these  theories  much 
experimental  work  has  been  done  on  the  subject,  and  although 
much  valuable,  practical  information  has  been  gained  in  this  way 
yet  the  ultimate  fate  of  the  graft  has  not  been  conclusively  de- 
termined.    From  a  practical  standpoint  we  are  not  so  much  in- 

771 


772  FRACTURES   AND   DISLOCATIONS 

terestod  in  the  theories  as  we  are  in  knowing  the  eonditions  under 
wliieli  bone  may  ])e  sueeessfnlly  trans[)hnited  to  iill  in  defeets  in 
the  skeleton..  Moreover  it  is  not  sufficient  to  know  that  under  cer- 
tain conditions  the  operation  maif  he  successfully  ix'rt'ornied  but 
we  nuist  know  just  wliich  methods  will  give  the  hij^'hest  percentage 
of  success,  and  just  what  conditions  ai-e  most  likely  to  interfere 
with  the  "taking''  of  the  graft. 

In  order  that  we  may  develop  the  practical  side  of  the  subject 
we  must  examine  into  the  results  obtained  in  some  of  the  more 
recent  experimental  work  and  consider  these  facts  together  with 
the  theories  just  refei-red  to  and  what  we  know  of  the  embryonic 
development  of  bone  and  the  repair  of  fractures.  Following  frac- 
ture certain  tissues,  as  far  as  we  can  determine,  resume  their  em- 
bryonic function  and  produce  bone  to  repair  the  lesion.  In  the 
embryo  the  bone-forming  tissues  seem  to  be  the  periosteum  and 
the  osteoblast,  but  whether  or  not  the  l)one-forming  properties  of 
the  periosteum  are  inherent  to  this  membrane  or  are  dependent  on 
the  osteoblast  cannot  be  stated.  The  bone  cell  is  developed  from 
the  osteoblast,  and  in  the  presence  of  fracture  it  is  not  improbable 
that  the  bone  cell  reverts  to  its  embryonic  role  and  produces  bone 
provided  circulation  is  not  destroyed.  It  would  therefore  seem 
that  in  the  repair  of  a  fracture  ossification  of  the  soft  callus 
emanates  from  three  sources:  namely,  the  periosteum,  the  endos- 
teiim,  and  from  the  osteoblasts  within  the  bone  near  the  frac- 
tured surfaces  of  the  fragments.  If  the  bone-forming  properties 
of  th€  periosteum  and  endosteum  depend  on  the  osteoblasts  then 
the  process  of  ossification  resolves  itself  into  one  word,  viz.,  osteo- 
blast. A  transplant  might  be  considered  as  an  ordinary  fragment 
if  it  were  not  for  the  fact  that  its  circulation  has  been  disturbed 
by  being  removed  from  its  original  position.  This  is  a  most  im- 
portant matter  since  the  life  of  the  bone  cell,  and  hence  of  the  bone 
itself,  depends  on  an  adeciuate  circulation.  It  is  an  established  fact 
that  if  a  section  of  periosteum  be  stripped  up  from  the  bone  and 
transplanted  into  other  tissue  (muscle  for  example),  it  is  capable 
of  living  and  producing  bone.  Now  a  normal  bone  receives  its 
circulation  from  three  sources :  the  periosteum,  endosteum  and  the 
direct  ramifications  of  the  nutrient  vessel  or  vessels.  In  remov- 
ing a  graft  the  branches  of  the  nutrient  artery  are  of  course  put 
out  of  function,  but  if  the  periosteum,  when  transplanted,  can 
continue  to  live  and  reestablish  its  circulation,  it  is  capable,  to  a 


BONE   TRANSPLANTATION  773 

greater  or  less  extent,  of  taking  care  of  the  attached  bone  and  its 
contained  bone  cells.  In  considering  the  circulation  of  the  graft 
and  its  periosteum  it  should  be  remembered  that  the  function  of 
circulation  (namely,  the  supply  of  oxygen  and  nutrition  and  the 
removal  of  waste  products)  can,  to  some  extent  be  directly  ac- 
complished by  diffusion,  osmosis,  dialysis  and  infiltration  within 
the  fluids  surrounding  and  pervading  the  transplant.  A  graft 
stripped  of  its  periosteum  may  live,  when  transplanted,  but  the 
chances  of  its  doing  so  are  much  less  than  when  the  membrane 
is  left  attached.  A  periosteum-free  transplant  is  more  likely  to 
survive  if  broken  up  into  small  pieces,  since  the  fluids  thus  obtain 
freer  access  to  the  bone  cells.  On  the  other  hand  it  is  well  known 
that  under  favorable  circumstances  dead  bone  (sterilized  by  boil- 
ing and  hence  killed)  has  been  successfully  grafted  into  defects  in 
the  skeleton  and  what  would  seem  still  more  remarkable  inorganic 
materials,  such  as  bars  of  magnesium,  have  been  placed  between 
the  fragments  and  been  replaced  by  strong  living  bone.  The 
chances  of  transplanted  bone  living,  whether  periosteum-covered 
or  not,  are  increased  when  it  is  firmly  contacted  with  living  bone. 
These  facts  would  seem  to  indicate  that  Murphy's  theory  is  cor- 
rect, in  as  far  as  ossification  may  take  place  from  osteogenetic  ele- 
ments passing  from  the  ends  of  the  fragments  into  the  substance 
of  the  graft.  Magnesium  as  a  graft,  however,  has  had  only  fair 
success  even  in  regions  of  greatest  vascularity,  such  as  the  face. 

It  would  seem  apparent  therefore  that  the  periosteum,  endosteum 
and  the  osteoblast  (whether  situated  in  the  graft  or  in  the  frag- 
ments) are  each  capable  of  producing  bone  under  favorable  cir- 
cumstances and  that  therefore  the  technique  most  favorable  to  the 
activity  of  all  of  these  elements,  will  show  the  highest  percentage 
of  success. 

The  transplant  does  not  need  to  be  as  heavy  as  the  section  of 
bone  which  it  is  to  replace.  If  the  operation  is  successful  and  the 
transplant  lives,  it  will  increase  in  diameter  until  it  is  capable  of 
properly  withstanding  the  full  strain  to  which  the  bone  is  normally 
subjected.  This  increase  in  size,  however,  is  more  or  less  depend- 
ent on  the  use  of  the  member  after  the  graft  has  solidly  united. 
In  other  words,  if  the  member  into  which  the  graft  is  placed  is 
kept  at  rest  and  not  subjected  to  strain  after  union  of  the  trans- 
plant, the  volume  of  the  graft  cannot  be  expected  to  increase  in 
size  to  properly  take  up  its  function.     This  means,  therefore,  that 


774  FRACTURES   AND   DlSlA)CATIONS 

after  union  has  takon  jilacc  tlu>  nicnilioi'  should  be  gradually  sub- 
jected \o  increasing  sti'ain  unlil  the  transverse  diameter  of  the 
graft  has  augmented  sufficiently  to  take  up  its  full  function.  The 
progress  of  this  growth  is  best  determined  by  Rontgenograms  taken 
at  intervals  during  the  after-care  of  the  case. 

In  obtaining  a  graft  oidy  a  portion  of  llie  diameter  of  the  shaft 
from  which  it  is  taken  should  be  removed,  since  if  a  section  of  bone 
including  the  entire  diameter  with  its  periosteum  is  removed,  re- 
jniir  of  tlie  defect  with  Ixjiiy  tissue  cannot  l)c  expected.  When  a 
section  of  bone  is  taken  from  the  tihia  as  shown  in  Figs.  846, 
847  and  848,  the  space  left  in  the  crest  of  the  shin  is  entirely 
repaired  and  filled  in  with  living  bone. 

Exi)crience  has  demonstrated  that  the  i)rocedure  is  most  suc- 
cessful when  the  graft  is  taken  from  the  same  i)crson.  If  this  is 
not  possible  the  nearest  lilood  relative  should  be  chosen.  The  pros- 
pect of  failure  is  so  great  when  the  graft  is  taken  from  one  of 
the  lower  animals  that  this  source  has  been  entirely  discarded. 

In  order  that  we  may  arrive  at  a  i)rai'tical  working  knowledge 
of  the  subject  we  must  review  the  established  facts  as  determined 
by  clinical  experience  and  experimental  work  and  apply  them  ac- 
cording to  the  principles  of  modern  aseptic  surgery,  so  that  in 
a  given  case  the  most  favorable  conditions  for  the  operation  may 
be  obtained.  The  most  favorable  conditions  may  be  summed  up 
as  follows: 

1.  Absolute  asepsis.  The  most  rigid  asepsis  should  be  observed 
throughout,  in  exposing  the  fragments,  in  obtaining  the  graft  and 
finally  in  placing  it  in  position  to  fill  in  the  defect.  The  graft 
should  not  come  in  contact  with  the  gloved  hand  and  the  gloved 
hand  should  not  be  introduced  within  the  wound  if  possible  to 
avoid  it.  The  subject  of  asepsis  has  been  considered  under  the 
heading  of  "The  Open  Treatment  of  Fractures"  (Chapter  LIX, 
page  758).  One  should  never  attempt  bone  grafting  in  the  pres- 
ence of  a  discharging  sinus  or  infection  of  any  kind.  After  the 
sinus  or  diseased  area  has  healed  the  operation  may  be  attempted. 

2.  The  use  of  an  autoplastic  periosteum-covered  transplant. 

'•].  The  solid  contacting  of  transplant  with  living  bone;  at  both 
ends  if  possible. 

4.  It  is  essential  that  the  transplant  be  covered  with  viable  soft 
tissue.  The  thicker  the  edges  of  the  incision  the  more  soft  tissue 
there  will  be  to  close  over  graft. 


BONE    'J'ltANSPL.ANTATION  U ■) 

5.  The  avoidance,  as  Far  as  possible,  of  iion-absorl)a1)le  material 
in  fixing'  the  graft  in  place.  We  cannot  cxpcA-t  a  graft  to  show  as 
much  resistance  as  is  possessed  by  a  fragment  with  intact  circ^iia- 
tion. 

6.  The  graft  should  have  a  function  to  perform  as  previously 
explained.  A  graft  v^ill  not  develop  or  may  even  be  absorbed  if 
not  subjected  to  some  strain  after  union  has  taken  place. 

7.  In  obtaining  the  graft  the  entire  diameter  of  a  shaft  should 
not,  as  a  rule,  be  removed.  It  interferes  with  regeneration  of  the 
defect  thus  made. 

Indications. — The  conditions  in  which  bone  grafting  is  indicated 
are  numerous  and  the  future  will  probably  disclose  additional  uses 
for  this  procedure.  There  are  three  classes  of  conditions  which 
most  frequently  call   for  bone  grafting. 

1.  To  till  in  defects  in  the  skeleton. 

2.  To  produce  union  between  fragments  where  non-union  has 
existed. 

3.  For  the  immobilization  of  joints  and  the  support  diseased 
parts. 

1.  The  types  of  skeletal  defects  are  numerous  and  are  classified 
according-  to  the  etiologic  element.  They  may  be  the  result  of  con- 
genital defects,  destructive  infections,  tumor  formations  and 
trauma.  From  the  standpoint  of  fractures  and  dislocations  we 
are  interested  only  in  bony  defects  resulting  from  trauma.  In 
severe  compound  comminuted  fractures  a  large  section  of  a  bone, 
more  commonly  its  shaft,  may  be  destroyed  and  if  the  parts  become 
infected  (as  they  so  frequently  do,  seeing  that  the  injury  is  sus- 
tained under  septic  conditions)  additional  bony  tissue  may  be 
destroyed.  The  end  to  be  attained  in  such  cases  is  to  clear  up 
the  infection  and  obtain  healing  of  the  wound.  If  necrotic  bone 
is  present  it  should  be  removed.  (See  following  chapter  on  the 
treatment  of  compound  fractures  and  luxations.)  When  the  parts 
are  thoroughly  healed  an  attempt  should  be  made  to  fill  the  bony 
defect  by  bone  grafting.  The  most  satisfactory  technique  will 
usually  be  found  to  be  the  medullary  graft  or  the  inlay  graft  as 
described  by  Albee. 

2.  Non-union  is  a  condition  which  in  many  cases  can  only  be 
corrected  by  bone  grafting.  After  non-union  has  existed  for  some 
time  the  ends  of  the  fragments  become  sclerosed  and  often  ebur- 
nated  and  seem  to  lose  their  power  of  forming  bone  or  at  least 


77U  FRACTURES   AND   DISLOCATIONS 

are  too  di'iise  to  allow  tlie  peiictfation  of  lioiit'-foniiiiiii'  clciiicnts. 
I'lKlcr  siicli  conditions  hone  «:rafliiiii'  is  tlic  onl\'  way  in  wliich  union 
can  !)('  obtained.  The  niedullai'v  and  inla\'  ural'ts  are  the  most 
satisfactory  methods  of  transplaidin*;"  hone  to  correct  non-union. 
Tlie  iiday  irraft  seems  to  he  uainiiiii;  favor  over  the  medullai'y  trans- 
phiiit  in  this  type  of  work,  although  the  techniiiue  is  more  difficult 
and  requires  more  special  apparatus. 

3.  For  the  purposes  of  sui)port  and  arthrodesis  bone  transplan- 
tation is  rarely  called  for  in  tlie  treatment  of  fractures  and  dis- 
locations. Instability  of  the  knee  .joint  following-  injury  can,  as  a 
rule,  he  corrected  by  rei)air  of  the  ci'ucial  and  latei'al  ligaments. 

Technique. — Bone  grafting  is  by  no  means  a  new  subject  but  it 
is  only  within  the  last  few  years  that  it  has  been  widely  employed 
and  this  is  because  of  the  improved  results  obtained  by  the  more 
recent  technique.  It  is  apparent  that  in  the  evolution  of  a  subject 
such  as  this  a  great  variety  of  methods  are  evolved  and  discarded 
before  a  satisfactory  technique  is  finally  develojjed.  A  detailed 
description  of  some  of  the  older  methods,  therefore,  would  be  of  in- 
terest from  an  historical  standpoint  only.  Among  those  which 
have  been  most  prominent  might  be  mentioned  the  following: 

1.  The  transplantation  of  living  bone  chips  to  fill  in  defects. 
As  much  of  the  periosteum  as  possible  should  be  left  attached  to 
each  chip.  This  method  is  deficient  in  that  it  does  not  afford 
fixation  and  the  manner  of  contacting  between  the  chips  and  frag- 
ments is  more  or  less  haphazard.  The  failures  accompanying  this 
method  are  much  greater  than  when  more  recent  technique  (to  be 
discussed  later)  is  employed.     It  is  now  obsolete. 

2.  The  transplantation  of  dead  bone,  either  as  chips  or  in  one 
large  fragment.  This  method  does  not  give  as  high  a  percentage 
of  success  as  the  transplanting  of  living  bone  chips  and  is  not  em- 
ployed at  the  present  time. 

3.  The  transplantation  of  bone  or  periosteum  by  means  of  the 
flap  method  in  which  the  graft  is  raised  from  one  region,  turned 
on  its  pedicle  and  inserted  into  the  bone  in  which  the  defect  is 
to  be  filled  in.  This  technique  is  difficult,  limited  in  application 
and  shows  no  advantage  over  the  use  of  the  free,  periosteum-cov- 
ered transplant.  It  is  for  the  most  part  discarded  at  the  present 
time  although  there  are  certain  conditions  in  which  it  may  be  used 
to  advantage.  Prominent  among  these  is  the  filling  in  of  defects 
in  the  tibia  bv  using  the  fibula  of  the  same  leg  and  in  filling  in 


BONE    TRANSPTvANTATION  777 

defects  in  one  oi"  tlic  bones  ol'  the  torciarm  l)y  a  ^^ral't  taken  from 
the  other  bone.  This  will  he  discussed  Inter  nnder  "Rcfi:ional 
Teclniique." 

4.  The  grafting  of  foreign  materials  into  defects.  Some  remark- 
able work  has  lieen  done  along  these  lines.  Magnesium  has  been 
grafted  into  the  defect  and  been  absorbed  and  replaced  by  living 
bone.  A  silver  framework  has  been  made  to  replace  a  large  sec- 
tion of  the  lower  jaw  and  after  being  placed  in  position  has  been 
surrounded  by  bone,  but  such  a  result  cannot  be  expected  in  any 
but  the  most  vascular  regions  such  as  the  face  and  even  then  failure 
is  likely  to  result.  Absorbable  and  non-absorbable  materials  have 
been  discarded  in  favor  of  the  living  periosteum-covered  trans- 
plant. 

We  are  warranted  in  employing  only  the  methods  which  are 
known  to  produce  the  highest  percentage  of  success.  At  the  pres- 
ent time  the  transplantation  of  a  large,  free,  periosteum-covered 
transplant  is  the  method  which  produces  the  best  results.  The 
manner  in  which  this  may  be  accomplished  has  varied  in  the  hands 
of  different  surgeons  and  according  to  the  region  involved.  The 
technique  of  modern  bone  transplantation  in  the  treatment  of  frac- 
tures may  be  considered  under  the  following  headings : 

1.  The  medullary  graft  or  dowel  method. 

2.  The  inlay  graft. 

3.  Regional  or  special  technique   in  which  the  procedure  is 

adapted  to  certain  regions. 

1.  The  Medullary  Graft  or  Dotvel  Method. — It  would  seem  un- 
necessary to  repeat  that  first  class  operating  room  facilities  should 
be  available  and  that  the  surgeon  be  experienced  in  bone  work. 
These  conditions  and  the  observance  of  the  most  rigid  asepsis  are 
essential. 

The  fragments  are  exposed  and  the  ends  freshened  with  saw, 
chisel,  burr,  gigli  saw  or  motor  saw  according  to  the  preference  of 
the  surgeon.  The  older  the  fracture  the  more  important  is  this 
freshening  of  the  ends  of  the  fragments.  If  the  ends  are  much 
sclerosed  it  may  be  advisable  to  remove  considerable  bony  tissue. 
If  overriding  deformity  exists  it  should  be  corrected,  when  possible, 
by  traction  on  the  limb.  In  old  cases  it  may  be  impossible  to 
bring  the  member  back  to  its  original  length  and  in  such  instances 
enough  bone  should  be  removed  from  the  ends  of  the  fragments 


778 


FRACTURES    ANH    DISLOCATIONS 


to  allow  tho  overriildi'ii  fragmonts  to  be  brought  baek  into  align- 
iiiciil.  Till'  lucduUary  cavity  of  each  fragment  is  then  reamed  out 
with  a  hm-r  or  drill  to  reeeive  the  ends  of  tiie  transplant.     IMnrphy 

has  dcvisrd  special  hiin's  I'm*  this  ])nrpos('  but  the  authoi-  has  found 


I'iK.    84 


Fig.   845. 


Fig.  84.T. — Old  ununited  fracture  of  tibial  shaft  with  rounding  of  ends  of  frag- 
ments  and   interposition   of   fibrous   tissue. 

Fig.'  844.- — Same,  after  ends  of  fragments  are  squared  off  and  medullary  cavity  in 
fragments  reamed  out  to  receive  the  graft. 

Fig.   845. — Same,   after   medullary    dowel    graft    has    been    placed    in    position. 


that  the  work  may  be  quite  satisfactorily  done  with  an  ordinary 
machinist's  breast  drill. 

Tire  wound  is  then  lightly  packed  witli  gauze,  Avhich  has  been 
wrung  out  of  physiologic  salt  solution,  and  is  thus  protected  while 
the  graft  is  being  obtained.  The  graft  may  be  taken  from  the 
fibula,    crest   of   ilium,   upi)er   third    of   ])ostcrior   border   of   ulna. 


RONK    TKANSI'LANTATION 


779 


clavicle,  etc.,  hut  the  crest  of  the  tihia  is  the  favorite  site  and  unless 
there  is  some  special  contraindication  the  ti'ans|)hiiit  should  be 
taken  from  this  l)one.     Tlic  libiji  is  exposed  and  the  tibialis  jiiiticus 


Fig.   S4() 


84S. 


Fig.  846. — Mailing  saw  cuts  in  obtaining  medullarj'  graft.  Tlie  distance  between 
the  saw  caits  represents  tlie  lengtli  of  the  desired  graft. 

Fig.  847. — Removing  medullary  graft  with  chisel.  Grooves  are  cut  with  tlie 
chisel  and  deepened  until  the  medullary  cavity  is  entered.  The  grooves  should  be 
deeply  cut  before  an  attempt  is  made  to  remove  the  graft,  as  otherwise  it  may  be 
split. 

Fig.  848. — Removing  medullary  graft  with  rotary  motor  saw.  (See  Fig.  851.) 
The  saw  should  be  kept  under  a  stream  of  sterile  salt  solution  to  prevent  heating  and 
devitalization  of  bone  tissue. 


cut  away  from  that  portion  of  the  external  surface  which  is  to  be 
included  in  the  graft.  Two  transverse  saw  cuts  are  made  in  the 
crest  of  the  bone,  the  distance  between  them  being  the  length  of  the 


780  FRACTITRKS    AND    OlSLOCATIONS 

desired  ji;raft.  (See  Fi^.  840.)  jMeelianie's  dividers  or  enlipers 
tire  siM'vieeable  in  traiisren-inj;  llie  iiieasiirciiu'iit  fi'oiii  llic  injured 
iiiciiilifr  to  I  lie  site  from  whidi  the  graft  is  to  be  lakcii.  Tlie  uraft 
should  Ik-  lon^j  onon«>h  lo  bi-id^c  tlie  defect  and  t-xlend  into  the 
uK'dullary  cavity  oi'  each  fratiment  sni'liciently  to  obtain  proper 
IcNfrauc  Two  grooves  are  next  made  on  eitlier  side  of  the  crest 
ol'  the  tibia  and  api)roxiniately  parallel  to  it.  The  cuds  oi"  the 
saw  cuts  aiv  thus  connected.  A  carpenter's  chisel  (without  the 
wooden  handle^  makes  a  very  satisfactory  instrument  for  cutting 
these  iji'ooves  as  shown  in  Fig.  847.  Care  should  he  exercised  in 
making  thes(>  gi'ooves,  not  to  split  the  graft;  they  should  be  deeply 
cut  before  an  attem])t  is  made  to  drive  the  chisel  into  the  medullary 
cavity  and  thus  raise  the  graft  and  sepai'ate  it  from  the  rest  of  the 
bone.  The  graft  should  be  about  the  size  of  the  index  finger  if  it 
in  to  he  transplanted  into  one  of  the  lai-ger  hones,  and  correspond- 
ingly smaller  if  it  is  to  he  iised  in  one  of  the  smaller  long  hones. 
The  graft  thus  removed  is  trihedral,  two  of  its  sides  are  covered 
with  periosteum  while  the  third  corres])onds  to  the  medullary  cav- 
ity and  is  covered  with  endosteum.  The  ends  are  then  cut  with 
bone  cutting  forceps  so  that  they  will  he  slightly  tapered,  thus 
facilitating  their  introduction  into  the  medullary  cavities  of  the 
fragments  and  insuring  a  good  tit  and  solid  contacting  between 
the  graft  and  the  fragments.  The  transplant  should  be  handled 
only  with  instruments  and  should  be  shaped  and  placed  in  jDOsition 
as  rapidly  as  possible.  Washing  the  graft  in  salt  solution  is  not 
advisable.  After  the  graft  is  removed  the  wound  made  in  securing 
it  is  lightly  packed  with  moist  gauze,  and  after  the  ends  have  been 
shai)ed  one  end  of  the  transplant  is  driven  into  the  reamed  out 
medullary  cavity  of  one  of  the  fragments  until  solidly  seated. 
The  opposite  end  is  then  driven  into  the  medullary  cavity  of  the 
other  fragment.  When  seated  the  graft  should  afford  considerable 
support  to  the  extremity.  If  the  operation  is  done  because  of 
non-union  and  there  is  very  little  loss  of  bony  tissue  the  fragments 
may  come  in  contact  over  the  graft  and  entirely  cover  it.  If, 
however,  grafting  is  indicated  because  of  loss  of  tissue  in  a  shaft 
as  well  as  non-union,  it  will  he  best  to  shape  the  graft  so  that  the 
fi-agments  will  solidly  engage  with  it  before  they  come  together. 
(See  Fig.  84;").)  The  graft  is  thus  made  to  bridge  the  defect  and 
overcome  shoi-leuing  of  the  member.  If  the  shaping  of  the  graft 
is  not  carefully  done  one  or  both  ends  may  slip  into  the  medullary 


BONE    TRANSPLANTATION  781 

cavity  Further  than  desired  and  affoi'd  only  n  l()os(^  seatirif^  and 
allow  shortening  of  the  bone.  This  trouble  chii  l)e  correeted,  to 
some  extent,  by  using  nails,  pegs,  sutures,  (!tc.,  but  there  is  nolhing 
which  will  take  the  place  of  a  solid  contacting  at  th(;  [)roper 
points.  If  the  graft  enters  a  fragment  too  far  a  hoh;  may  be 
drilled  transversely  through  the  fragment  and  graft,  and  a  nail 
driven  in  place  thus  holding  the  graft  in  the  desired  position. 
Instead  of  the  nail  a  heavy  strand  of  kangaroo  tendon  may  be 
passed  through  the  hole  and  tied  about  the  end  of  the  fragment. 
What  will  answer  the  purpose  still  better,  especially  if  Albee's 
doweling  machine  is  at  hand,  will  be  to  '  secure  additional  bone 
from  the  site  from  which  the  graft  was  taken  and  make  from  it 
a  peg  of  bone  of  proper  size  to  be  driven  into  the  hole  passing 
through  the  end  of  the  fragment  and  transplant.  Foreign  ma- 
terial, especially  that  which  is  non-absorbable,  should  be  avoided  as 
far  as  possible  in  fixing  the  graft  in  position  since  the  resistance 
of  the  transplant  is  lessened  by  the  circulatory  disturbance  re- 
sulting from  its  removal.  Excellent  results  have  been  obtained 
even  when  the  ends  of  the  graft  have  been  secured  in  position 
by  nails  or  wire  but,  as  previously  stated  in  this  chapter,  it  is 
incumbent  on  us  to  follow  the  methods  affording  the  highest  per- 
centage of  success  and  the  use  of  foreign  non-absorbable  materials 
in  fixing  the  graft  is  more  likely  to  be  followed  by  trouble  or 
failure  than  when  such  material  is  not  employed.  In  obtaining 
the  graft  the  work  may  be  a  little  more  rapidly  and  neatly  done 
if  a  circular  motor  driven  saw  is  used. 

In  instances  in  which  there  is  considerable  loss  of  bone  and  the 
graft  must  be  depended  upon  to  maintain  the  length  of  the  mem- 
ber without  the  ends  of  the  fragments  coming  in  contact,  the  medul- 
lary graft  is  probably  superior  to  other  methods.  AVhere  there 
is  not  great  less  of  bony  tissue  and  the  element  of  non-union  is  the 
important  factor  better  results  are  claimed  for  the  inlay  graft. 

2.  Tlie  Inlay  Graft. —  (Albee's  technique.)  The  fragments  are 
exposed  and  the  ends  freshened  as  already  described  in  preparing 
the  fragments  for  the  medullary  graft.  It  is  an  extremely  diffi- 
cult matter  to  carry  out  this  technique  without  the  twin  motor 
saw  as  used  by  Albee  and  if  such  is  not  available  one  had  better 
employ  the  medullary  graft. 

A  longitudinal  incision  is  made  through  the  periosteum  and  the 
edges  turned  back  to  expose  the  cortex  of  the  bone  in  Avhich  the 


782 

truttcr  is  to  III- 


FRACTURKS    AND    DISLOCATIONS 


•lit  to  i'('i'ci\i'  tlic  Lirat'l.  Two  loiiuit iidiiial  parallel 
saw  cuts  arc  iiiadc  witii  the  twin  saws  acfoss  the  |)laiK'  of  frac- 
ture and  extendiiiij  into  cadi  ria'^mciit  for  a  distance  of  two  and  a 
half  to  throe  inches.     These  cuts  pass  ttu-ouiiii  the  coi'tex  into  the 


W^i 


V 


Fig.    849. 

Fig'.  849.— Inlay  graft  in  place.  Albee's  tefhiiique  in  cases  of  non-union.  'I'lio 
twin  motor  saws  are  almost  essential  in  cutting  the  gutter  to  receive  the  graft  aiul  in 
obtaining  the  graft  from  the  tibia. 

Fig.  850. — Method  of  securing  inlay  graft  in  place  with  kangaroo  Iciulon  as  advo- 
cated  by   Albee. 

medullary  cavity  of  the  fragments.  Care  sliould  lie  exercised  in 
using  the  saws  to  see  that  they  follow  straight  lines  as  otherwise  the 
fitter  will  show  a  lateral  curvature  which  will  Iw  ditficult  to  tit 
with  the  graft.  Albee  advises  that  the  saws  be  adjusted  to  a  dis- 
tance of  •)i(;  to  %(;  of  an  inch  from  each  other  according  to  the 
size  of  the  bone  operated  upon.  In  cutting  the  groove  the  saw^s 
should  be  kept  under  a  stream  of  salt  solution  to  prevent  heating 
of  the  bone  which  tends  to  devitalize  it.  The  bone  is  finally  re- 
moved from  the  groove  by  cutting  the  ends  with  a  small  osteotome 
so  as  to  make  a  tongue  and  groove.     (See  Fig.  849.)     Either  two 


BONE    TRANSIT^ANTyVTION 


783 


or  four  holes  (according  to  the  needs  of  the  case)  are  llicii  diago- 
nally drilled  through  the  cortex  on  both  sides  of  the  groove  and  in 
both  fragments.  These  holes  are  drilled  in  i)airs  op|)Osite  each 
other,  as  shown  in  Fig.  849,  and  through  each  pair  of  holes  is  passed 
a  double  strand  of  heavy  kangaroo  tendon.  The  fragments  are 
now  ready  for  the  graft.     The  wound  is  then  lightly  packed  with 


Fig.   851. — Motor   saw   equipment    including   twin   saws. 


Fig.   852. — Doweling   machine. 

moist  gauze  and  the  surgeon  turns  his  attention  to  securing  the 
graft  to  fill  the  gutter. 

The  internal  surface  of  the  tibia  is  next  exposed  and  the  dimen- 
sions of  the  desired  graft  are  mapped  out  on  the  periosteum  with 
a  scalpel.  The  twin  saws  are  then  employed  (without  changing 
their  adjustment)  and  a  strip  of  bone,  the  same  size  as  the  gutter 
prepared  in  the  fragments,  is  removed.  The  ends  of  this  graft 
are  then  pointed  with  the  saw  to  conform  to  the  ends  of  the  groove 
in  the  fragments.  The  graft  is  next  transferred  and  the  wound 
filled  with  a  moist  pack.     One  strand  of  kangaroo  tendon  is  then 


784 


FRACTURES    AND    DISLOCATIONS 


pulk'd  uj)  Trom  tlie  m(_-duUary  cavity  Ix-twoeii  each  pair  of  lioles 
previously  ilrilled  in  the  fragments  and  the  graft  placed  under 
these  raised  strands.  The  ends  of  the  sutures  i)rojecting  from  the 
drill  holes  are  tied  and  the  graft  thus  secured  in  place.  (See  Pigs. 
849  and  850.)  Tiie  tongue  and  groove  effect  at  the  ends  of  the 
graft  causes  the  ends  of  the  ti'ansplant  to  become  firmly  engaged 
when  extension  is  removed  and  the  muscles  of  the  extremity  con- 


Fig.  853. 


Pig.   854. 


Fig.    855. 


Fig.  853. — Fir.st  step  in  Albee'a  technique  in  recent  fractures.  Superficial  cuts 
are  made  with  the  twin  saws  and  then  each  cut  is  finished  with  a  single  rotary  saw 
so  that  the  section  of  bone  removed  will  be  wedge-shaped. 

Fig.  854. — Second  step.  Short  piece  is  removed  to  be  cut  up  longitudinally  to 
be  used  in  making  bone  pegs  with  the  doweling  machine.      A.  shows  short  piece  removed. 

Fig.  855. — Third  step.  Long  piece  has  been  slid  to  opposite  end  of  gutter  so 
that  it  crosses  the  line  of  fracture  and  is  held  in  place  by  means  of  obliquely  driven 
bone  pegs.      B.  is  a   cross-section   showing  manner  in   which  oblique  pegs  hold   graft. 

tact,  while  the  kangaroo  tendon  sutures  maintain  the  fragments 
and  graft  in  alignment.  The  older  the  case  of  non-union  and  the 
more  sclerosed  or  eburnated  the  ends  of  the  fragments,  the  longer 
the  graft  should  be,  thus  insuring  bone-forming  activity  by  extend- 
ing well  into  the  substance  of  each  fragment.  It  is  claimed  that 
this  method  gives  better  results  in  old  cases  of  non-union  because 


BONE   TRANSPLANTATION  785 

of  the  greater  surface  of  contact  between  graft  and  fragments.  On 
the  other  hand  it  is  certain  that  the  inlay  graft  does  not  occupy 
as  good  a  position  from  a  mechanical  standpoint  as  does  tin;  medul- 
lary transplant,  and  when  heavy  muscular  contraction  and  shorten- 
ing are  to  be  overcome  (as  in  fracture  of  tiie  femur)  the  latter 
will  be  found  the  safer  technique.  It  is  probal)]y  not  wise  to 
attempt  the  inlay  method  unless  the  motor  saw  (^(|uipm(Mit  is  avail- 
able. 

Albee's  Technique  in  Recent  Fracture. — Albee  employs  a  modi- 
fied inlay  graft  in  the  operative  treatment  of  recent  fractures. 
The  twin  motor  saw  and  the  doweling  machine  are  essential  to  this 
technique.  The  fragments  are  exposed  and  approximated.  With 
the  twin  motor  saw  (the  blades  being  adjusted  to  about  Y-iQ  of  an 
inch  apart)  two  longitudinal  superficial  cuts  are  made  crossing 
the  line  of  fracture  as  shown  in  Fig.  853.  The  saws  should  follow 
straight  lines  and  the  cuts  should  extend  about  twice  as  far  on 
one  side  of  the  plane  of  fracture  as  on  the  other.  A  single  motor 
saw  is  then  used  to  complete  the  cuts  into  the  medullary  cavity. 
The  cuts  are  not  made  in  parallel  planes  but  are  so  placed  that 
the  periosteal  surface  of  the  graft  is  about  one-fourth  of  an  inch 
wider  than  is  the  endosteal  surface.  Thus  by  making  a  wedge  of 
the  graft  it  will  be  impossible  for  it  to  be  displaced  into  the  medul- 
lary cavity.  The  short  piece  of  the  graft  is  removed  and  the 
long  piece  slipped  to  the  opposite  end  of  the  groove  so  that  it 
crosses  the  line  of  fracture.  (Fig.  855.)  The  short  piece  of  the 
graft  is  then  cut  up  with  the  motor  saw  and  converted  into  pegs 
with  the  doweling  machine.  Oblique  holes  are  next  drilled  into 
the  fragments  on  each  side  of  the  graft  and  the  bone  pegs  driven 
home  so  that  their  ends  project  over  the  graft.  (See  Fig.  855.) 
Good  fixation  is  thus  afforded  if  the  technique  is  properly  carried 
out  and  the  great  claim  for  this  method  is  that  no  foreign  material 
is  left  imbedded  in  the  wound.  Albee  recommends  this  method 
as  a  substitute  for  the  Lane  plate. 

3.  Regional  or  Special  Technique. — The  methods  just  described 
will  meet  the  indications  in  practically  all  of  the  fracture  cases  in 
which  bone  grafting  is  indicated.  The  various  modifications  which 
have  been  employed  in  different  regions  of  the  skeleton  have  in 
almost  all  cases  been  devised  to  correct  conditions  resulting  from 
disease  or  defective  development,  and  hence  cannot  be  properly 
considered  as  coming  within  the  scope  of  this  work.     If  the  sur- 


786 


FRACTURES   AND    DISLOCATIONS 


.k't'on  api)ret'iat('s  the  })riiu'iples  involved  in  bone 
grafting-  and  tlie  techni(|ue  of  the  dowel  and  inlay 
grafts  lie  will  he  able  to  modify  his  Icchiuciue  to 
meet  the  exi'e[)tional  case.  Some  of  tiie  more  eoni- 
iiion  variations  may  be  mentioned.  The  entire 
upper  fiid  of  tlie  huiiierus  has  been  rei)laeed  with 
the  upper  eiul  of  the  fibula.  A  longitudinal  in- 
cision exi)Oses  the  region  previously  occupied  by 
the  u[)per  end  of  the  humerus.  The  end  of  the 
rragmeiit  is  fresliened  and  its  metluUary  cavity 
reametl  out.  The  upper  end  of  the  fibula  is  next 
exposed  and  the  length  of  the  desired  graft 
marked  on  its  shaft.  It  is  then  cut  across  and  the 
cut  end  inserted  into  the  reamed  out  medullary 
cavity  of  the  humenis  while  the  ligaments  and 
muscles  of  the  shoulder  are  sutured  about  the 
upper  end  of  the  bone  when  placed  in  the  glenoid 
cavity.  In  a  similar  maimer  the  lower  end  of  the 
radius  has  been  replaced  by  transplanting  the 
upper  end  of  the  fibula.  The  shaft  of  the  tibia 
may  be  replaced  by  the  shaft  of  the  fibula  without 
completely  detaching  the  fibular  shaft  from  its 
surrounding  soft  tissue.  The  operation  is  usually 
done  in  two  stages  though  it  may  be  done  in  one. 
The  lower  end  of  the  upper  tibial  fragment  is  ex- 
posed, the  end  freshened  and  the  medullary  cav- 
ity reamed  out.  The  upper  end  of  the  fibula  is 
then  divided  and  carried  across  to  be  inserted  into 
the  upper  tibial  fragment  and  the  wound  closed. 
The  second  step  of  the  operation  consists  in  trans- 
planting the  lower  divided  end  of  the  fibula  into  the  lower  tibial 
fragment.  The  entire  tibia  has  been  replaced  in  congenital  ab- 
sence of  this  bone  by  using  the  fibula.  The  upper  end  of  the  fibula 
is  placed  against  the  femoral  condyles  while  the  lower  end  of  the 
bone  is  placed  against  the  astragalus.  In  loss  of  bony  tissue  in  one 
of  the  bones  of  the  forearm  (e.g.,  the  shaft  of  the  radius)  a  section 
of  the  shaft  has  been  raised  from  the  ulna  and  grafted  into  the 
radial  defect  without  severing  the  pedicle  attached  to  the  trans- 
plant. In  an  operation  of  this  kind  only  a  portion  of  the  shaft  of 
the  ulna  should  be  removed.     In  old  ununited  fracture  of  the  neck 


Fig.  856.  —  Dia- 
gram, showing  man- 
ner in  whicli  upper 
end  of  humerus  may 
be  replaced  by 
grafting  of  upper 
end  of  fibula.  Sel- 
dom called  for  in 
the  treatment  of 
fractures  but  illus- 
trates one  of  the 
adaptations  of  bone 
grafting. 


BONE    TRANSPLANTATION  787 

of  the  femur  excellent  results  have  been  obtained  by  driving  a 
graft  taken  from  the  tibial  crest  through  the  trochanter  and  neck 
of  the  bone.     The  principles  involved  are  the  same  as  described  in 


Fig.   857.  Fig.   858.  Fig.   SoE 

Fig.    857. — Loss  of  tibial  shaft. 

Fig.  858. — First  step  in  replacing  tibial  shaft  by  shaft  of  fibula.  The  fibular 
shaft  is  divided  and  implanted  into   the  upper  tibial   fragment. 

Fig.  859. — Completion  of  operation.  The  lower  end  of  fibular  shaft  has  been  im- 
planted into  lower  tibial  fragment. 

the  "Operative  Treatment"  of  "Fractures  of  the  Upper  End  of 
the  Femur"  (page  550),  except  that  a  graft  is  used  instead  of  a 
screw  or  "screw-plate."  The  knee  has  been  replaced  by  the  same 
joint  taken  from  a  freshly  amputated  leg  and  the  metatarso- 
phalangeal joint  has  been  excised  and  grafted  into  an  ankylosed 
elbow  of  the  same  patient. 


788  FRACTFRES   AND    DISLOCATIONS 

It  is  manifestly  iiuiiracticablc  at  llu'  present  time  to  enter  into 
all  the  possible  variations  of  hone  "grafting  and  a  consideration  of 
the  conditions  in  which  it  may  be  indicated.  If  the  principles  of 
this  procedure  are  iniderstood  and  the  conditions  under  which  it  is 
most  likely  to  be  successful  are  fully  appreciated  the  surgeon's 
mechanical  sense  and  ingenuity  should  be  sutificient  to  enable  him 
to  modify  his  techni(|ue  to  meet  the  requirements  in  a  given  case 
of  exceptional  needs. 


CHAPTER  LXI. 

TREATMENT  OF  COMPOUND  FRACTURES 
AND  DISLOCATIONS. 

The  advent  of  asepsis  and  the  improved  technique  of  recent  years 
has  greatly  reduced  the  percentage  of  bad  results,  previously  so 
high,  following  compound  fractures  and  luxations.  Compound 
fractures  are  common,  but  it  is  unusual  to  see  a  dislocation  which 
exposes  the  joint  except  in  luxations  of  the  fingers.  The  more  com- 
mon luxations  are  almost  invariably  closed. 

The  principles  involved  in  treatment  are  practically  the  same 
whether  the  condition  be  a  fracture  or  dislocation,  and  accordingly 
the  two  conditions  will  be  considered  together.  Immediate  reduc- 
tion is  the  natural  tendency  as  soon  as  the  case  is  seen  but  in 
many  instances  nothing  more  detrimental  could  be  done.  The 
exposed  fragment  or  articular  surface  must  be  considered  infected, 
and  if  immediately  replaced  is  almost  sure  to  be  followed  by  sup- 
puration of  the  tissues  with  which  it  has  come  in  contact.  ]\Iany 
compound  fractures  and  dislocations  are  produced  by  penetration 
from  without,  and  in  these  cases  we  do  not  have  to  deal  with  a 
projecting  fragment  or  articular  end. 

When  a  compound  fracture  or  luxation  is  first  seen  the  wound 
should  be  covered  with  a  sterile  dressing  and  the  patient  removed  to 
surroundings  in  which  proper  surgical  procedures  can  be  carried 
out.  Sterile  surgical  dressings  may  not  be  at  hand,  in  some  in- 
stances, and  in  lieu  of  these  a  towel  fresh  from  the  laundry  is  a 
safe  substitute  to  use  in  covering  the  wound.  The  heat  of  ironing 
sterilizes  the  towel  fairly  well,  especially  as  done  in  the  modern 
steam  laundry,  and  if  the  towel  is  unfolded  so  that  a  fresh  surface 
comes  in  contact  with  the  wound  there  will  be  little  danger  of  infec- 
tion from  the  dressing,  and  the  wound  will  be  properly  protected 
during  transportation. 

An  anesthetic  is  advisable  in  most  cases.  With  the  patient  in 
the  operating  room  the  dressings  are  removed  and  the  skin  sur- 
rounding the  wound  painted  with  a  five  percent  tincture  of  iodine. 
The  edges  of  the  wound  are  then  inspected,  and  if  lacerated  and 

789 


IW  FKACTrRES    AND    DISLOCATIONS 

devitalized  tissue  is  present  it  should  lie  triinined  away  until  the 
margins  present  healthy  viabU'  tissue.  If  a  fragment  or  the  artic- 
ular end  of  <i  l)Oue  i)ro,ieets  through  the  wound  it  should  be  thor- 
oughly washed  with  stcrilf  |)liysiologic  salt  solution  until  all  foreign 
material  has  been  removi-d.  A  IVw  gallons  of  salt  solution  are  not 
too  much.  The  usual  fault  lies  in  too  little  washing.  After  the 
projecting  l)one  has  been  thoroughly  cleaned  reduction  is  effected 
and  the  wound  again  washed  with  a  few  gallons  of  sterile  salt  solu- 
tion. Internal  tixation  of  the  fragnu'uts  should  not  be  done  at 
this  time.  Foreign  nuitcrials  should  not  be  employed  to  secure 
fixation  unless  one  is  sure  of  asepsis  within  the  wound,  and  in 
compound  fractures  the  surgeon  can  never  be  sure  of  this  point. 
It  is  often  possible  to  obtain  a  solid  engagement  of  the  serrated  ends 
of  the  fragments  so  that  the  deformity  does  not  recur  wdien  proper 
splints  are  applied.  When,  however,  the  fragments  cannot  be  held 
in  good  reduction  it  is  better  to  close  the  wound,  obtain  healing 
of  the  soft  tissues  and  perform  a  secondary  operation  at  a  later  date, 
when  the  danger  of  infection  has  passed.  In  favorable  cases  the 
wound  will  be  healed  within  a  week  or  ten  days  and  the  surgeon 
may  then  expose  the  fragments  by  incision  and  employ  internal 
fixation  as  already'  described  in  the  "Operative  Treatment  of  Frac- 
tures" on  page  758. 

In  cases  in  which  suppuration  follows,  internal  fixation  can 
accomplish  no  good  and  is  capable  of  doing  considerable  harm. 
There  is  nothing  lost,  therefore,  when  internal  iixation  is  not  em- 
ployed at  the  first  operation  even  in  the  presence  of  recurrent 
deformity. 

The  essentials  in  the  operative  treatment  of  compound  fractures 
and  dislocations  are  the  thorough  and  free  washing  of  the  wound 
and  the  trimming  away  of  lacerated  and  devitalized  tissue.  The 
living  tissues  possess  a  certain  amount  of  resistance  to  infection 
which  increases  during  the  first  few  days  following  the  injury,  but 
devitalized  tissue  and  collections  of  dead  blood  within  the  wound 
possess  no  such  resistance  but  act  only  as  culture  media  for  the 
development  of  the  slight  infection  which  remains  even  after  the 
most  painstaking  attempt  at  removal  and  cleansing.  The  use  of 
antiseptics  within  the  wound,  such  as  solutions  of  bichlorid  of  mer- 
cury, are  not  only  useless  but  actually  harmful.  They  not  only 
have  little  influence  on  the  bact-eria  but  materially  reduce  the  resist- 
ance of  the  tissues. 


TREATMENT    OF    COMPOUND    FRACTURES    AND    DISLOCATIONS  791 

By  careful  attention  to  these  two  points  (washing  and  removal  of 
devitalized  tissue)  the  proportion  of  cases  in  which  suppuration 
follows  in  compound  cases  will  be  surprisingly  reduced.  When, 
however,  suppuration  follows  in  spite  of  this  treatment  drainage 
should  be  prompt  and  free,  and  attention  should  be  given  to  the 
cultivation  of  granulation  tissue  so  the  wound  may  heal  from  the 
bottom  in  the  shortest  time  possible.  The  fact  that  the  wound  is 
infected  does  not  mean  that  the  asepsis  employed  in  the  dressing 
of  the  wound  should  be  anything  but  the  most  rigid.  Even  though 
suppuration  is  present  it  should  not  be  forgotten  that  it  is  possible 
to  introduce  bacteria  of  other  strains  which  are  sometimes  produc- 
tive of  the  most  disastrous  results.  For  example  a  compound  frac- 
ture may  be  infected  with  pyogenic  bacteria  and  still  be  making 
good  progress  toward  recovery ;  if  some  virulent  infection,  such  as 
erysipelas  or  the  gas  bacillus,  gains  entrance  to  the  wound  the 
termination  may  be  fatal  within  a  short  time. 

The  use  of  the  so-called  antiseptics  within  the  wound  are  as  use- 
less and  harmful  here  as  in  the  initial  treatment  of  the  wound.  The 
chief  concern,  after  suppuration  is  established,  is  in  the  cultivation 
of  granulation  tissue  so  that  the  wound  will  heal  from  the  bottom 
and  cover  the  fragments.  In  order  that  this  may  be  accomplished 
drainage  should  be  free  and  fluids  coming  in  contact  with  the  gran- 
ulation tissues  should  be  isotonic,  and  the  dressings  should  not 
adhere  to  and  tear  the  granulation  tissue  when  removed.  Accord- 
ingly physiological  sterile  salt  solution  should  be  used  in  irrigating 
the  wound,  and  balsam  of  Peru  is  one  of  the  best  materials  to  stim- 
ulate the  granulation  tissue  and  prevent  it  from  adhering  to  the 
dressings.  Infection  in  a  compound  fracture  is  decidedly  detri- 
mental to  union  between  the  fragments,  but  it  does  not  necessarily 
mean  that  non-union  will  take  place.  Many  cases  are  shown  in 
the  preceding  pages  in  which  infection  was  present  and  still  perfect 
union  took  place.  In  some  fractures  there  may  be  considerable 
destruction  of  tissue  in  the  wound  which  renders  the  condition  com- 
pound, and  in  such  cases  it  is  often  advisable  to  do  a  plastic  sliding 
operation  so  the  wound  may  be  closed  even  at  the  expense  of  leaving 
some  adjoining  region  partially  denuded. 

In  compound  luxations  the  cleansing  and  trimming  away  of 
lacerated  tissue  involves  the  same  principles  as  already  described. 
If  suppuration  develops  subsequently  the  joint  should  be  aspirated 
and    injected    with    IMurphj^'s    formalin-glycerine    solution.     ]\Iore 


792  FRACTURES    AXD    nTST^OCATIONS 

than  one  aspiration  and  injection  iu;i.\  ])e  necessary  dnring  the 
after-treatment,  especially  if  the  joint  leaks  through  the  wound 
following  the  first  injection.  The  solution  injected  is  two  percent 
formalin  in  glycerine  and  should  be  made  up  the  day  before  it  is 
used.     Enough  of  the  fluid  should  be  injected  to  gently  distend 


Fig.    800. — CTungiene   following   ihronibosis. 

the  articulation.  Murphy  has  demonstrated  that  this  treatment  of 
suppurative  arthritis  gives  a  much  higher  percentage  of  good  func- 
tional results,  and  should  always  be  tried  out  before  open  drainage 
of  the  joint  is  resorted  to.  When  open  drainage  is  established  the 
result  is  almost  invariably  a  stiff  joint. 

The  results  in  compound  fractures  and  dislocations  depend 
largely  on  the  operative  treatment  immediately  following  the 
injury,  and  too  much  stress  cannot  be  laid  on  the  thorough  washing 
of  the  wound  and  the  trimming  away  of  lacerated  and  devitalized 
tissue. 


INDEX 


Abscess  of  brain,  443 

following  fracture  of  skull,  450 
symptoms  of,  443 

differential    diagnosis    of,    in    frac- 
ture of   skull,   443 
Absorbable   suture  material,   768 
Acetabulum,  fracture  of,  499 

complicating     dislocation     of     liip, 
520,  524 
Acromion,   fracture  of    (see  Fracture 

of  scapula,  37 ) 
Acute  flexion  of  elbow,  in  treatment 
of  fractures  of  elbow,  144, 
145 
Adjustable   splints   for   fracture  near 

elbow,    148 
After-care    (see  After-treatment) 
After-treatment    in, 

dislocation  of,  ankle,  690 
astragalus,   698 
calcaneum,   707 
carpo-metacarpal    joint,    296 
clavicle,  inner  end,  10 

outer  end,  36 
cuboid,  712 

cuneiform,   292    (see   Carpus) 
cuneiforms    of    tarsus,    712 
elbow,    171 
fingers,  318 
hip,    530 
jaw,   378 
knee,  619 
mandible,   378 
maxilla,  378 
OS    calcis,    707 
phalanges,    of    foot,    720 

of  hand,   318 
radius,  head  of,  182 
scaphoid,  of  carpus,  292 

of    tarsus,    712 
semilunar  cartilages,  592 
shoulder,   79 
spine,   490 

subastragalar    joint,   702 
subcoracoid   of   shoulder,    79 
subglenoid   of   shoulder,   79 
ulna,  lower  end,  240 
upper   end,    176 


793 


After-treatment,    dislocation — cont'd. 
wrist,  292 
fracture    of, 
astragalus,   698 
calcaneum,  707 
carpus,  292 
clavicle,  28 
cuboid,   712 
cuneiforms,   721 
femur,  lower  end,  784 

shaft,  572 

upper    end,    552 
fibula,  lower  end,  683    (see  Til)ia 
and  Fibula) 

shaft,   654 

upper   end,   631 
inferior  maxilla,  375 
jaw,  lower,  375 

upper,  346 
malar,  342 
maxilla,    inferior,    375 

superior,    346 
metacarpals,   306 
metatarsals,   718 
nasal  bones,   332 
olecranon,    190 
OS   calcis,    707 
patella,  605 

phalanges   of  hand,   312 
radial  and  ulnar  shafts,  228 
radius,    lower    end,    271 

shaft,    228 

upper   end,    202 
ribs,   463 
scaphoid,  292 
scaphoid  of  tarsus,   712 
scapula,    43 
semilunar,  292 
semilunar  cartilages,  592 
spine,   490 
sternum,   458 
superior  maxilla,  346 
tibia  and  fibula,  lower  ends,  683 

shafts,  654 

upper   ends,    631 
ulna,  lower  end,  235 

shaft,   228 

upper  end,   195 
zygomatic  arch,  342 


794 


INDEX 


Abloe's,  inlay  •ziat't,  7S1 

inlay  graft   in  nvcnt   fraitiin's,  TS") 
Allis'     nu^luul     of     rt>(lm-in'4     disloi-a- 

tions,  of  hi|),   o'iS 
Aniliiilatory    ])n('uniatic    s]>lint. 
for   fractuii'  of  liip.  .■)o4 
for    frai'turc    of    lc>r,    (ia.") 
for    fracturi'   of    tliigli,    oS.") 
Anatomical    nwk    of    Imnicrus.    frai-- 

turo    of,    S:? 
An<ilf"s   liands,    in    treatment   of   frac- 
tures of  jaw,   'M\,   'Ml 
.\iiulc"s    hands     and     l)avs,     in     treat 
inent    of    frartiires    of    jaw, 

Ani^le.  fraetnre-disloeations  of,  liS4 
aftercare,  «>!)() 
diaf»nosis,  (iS!) 
in'oiinosis,  (iOl 
siirjiical  anatomy,  684 
s\nii>toms,  6S7 
treatment.   ()8!) 

after-treatment,    (590 
o|ierative    treatment,    (i'lO 
Anomalies  of  carpus,  2S3 
Anomalous  ossification    of   ii])iier   end 

of  tibia,    622 
A])o])lectiform    attacks,    difYerent'ated 
from      unconsciousness     in 
fracture    of    skull,    44,") 
Asche    nasal    splints,    320 
A])0])lexy    differentiated    from    uncon- 
sciousness   in    fracture    of 
skull,  440 
Astrasialus,     fractures     and     disloca- 
tions   of,    602 
after-care,    608 
diagnosis,    605 
]iro2nosis,  608 
surgical  anatomy,  602 
s\mptoms,    604 
treatment,   605 

after-treatment,    605 
operative    treatment.    607 
Atlas     {see    Fractiu-e-dislocations    of 

spine.    465) 
Author's  method  of  reducin'f  disloca- 
tions   of    hi]),    526 
nasal    sulint,   ^M) 
screw-jjlate,    550,    551 
Avulsion    of    ui))ier   e.\tremit\",   6,3 
Axillary    pad.    08 

Axis      {see     Fracture-dislocations     of 
spine,    465) 


Bandage, 


four  tailed,    for    fracture   of 
jaw,   358 


bandage, — eovVd. 

Mohr's    tigure-of-eiizlit.    25 
Stiinson's,    for    dislocation    of   clav- 
icle,  35 
N'ellieau's,   25 

in   fracture  of  clavicle,  0 
Barton's   fracture,   251 
l?ase-hall    linger,    300 
Hase  of  skull    {see  Skull,  fracture  of, 

301) 
Battle's  sign,  420 
Bauer's    (|ualinn'ter,    746 
l?edsores,    in    fractures   of    s]iine,    400 
Bennett's    fracture,    200 
Beiioist,    radio-clironometer,    746 
I'igelow's    metliod    of    reduciii'^    dislo- 
cation   of    hip,    526 
^' -ligament  of,  516 
Blebs,   in   fracture  near  elbow,    120 

in  fracture  of  leg,  640 
Bodv  swathe,  in  fracture  of  liiimerus, 
101,   114 
in   fracture,  of  pelvis,  507 

of  ribs,   463 
used   with   T-si^lint.   544 
Bone    drill.    Lane's,    760 
Bone  forceps,  761 

Bone    grafting    {see    Bone    transplan- 
tation,  771) 
Bone   plates,   Lane's,   766 

Sherman's    modification    of,    765 
Boiu\    structure    of, 
in   clavicle,   12 
in    femur,   531,   575 
in  Inunerus,  83 
in    radius,   204 
in   tibia,   727 
in   ulna,  204 
B(mes  of  carpus,  iniur.ies  to,  277 

anomalies   of,   282 
Boiu'   transi)lantation,   771 
techni(|ue  of,  776 

Albee's   metliod,   for   nonun'on    in 
recent  fractures,  78:'> 
nu'dullarv  graft,   775,  777 
theories  of,  771 
I^race.    Tavlor's.    for    fractured    clavi- 

'  cle,  27 
Brain,    anatomv   of    i  srr   Skull,    frac- 
ture of,  302) 
abscess  of  brain,  symutoms  of.  443 

differential   diagnosis   of,   450 
coini)ression    of.    410 
concussion   of,  407 
coTitusion    of,   408 
inJTU'>'  to,  411 
laceration    of,   400 
membranes  of.  305 
Bryant's    triangle,    534 
Buck's  extension,  542 


INDEX 


795 


Cabot's  wire  splint, 

as    double    inclined    plane,    580 
in   fracture   of   thigh,   580 

of  leg,  040 
in   Pott  s  fracture,  609 
Calcaneum,     fractures     and     disloca- 
tions of,  703 
after-care,   707 
diagnosis,   700 
prognosis,  708 
surgical  anatomy,  703 
symptoms,   705 
treatment,  700 

after-treatment,   707 
operative  treatment,  706 
Carcinoma,    cause    of    fracture,    728, 

729,  731 
Carpal  bones    (see  Carpus,  277) 
Carpo-metacarpal  dislocations,   294 
after-care,   296 
diagnosis,    295 
prognosis,   296 
surgical   anatomy,   294 
symptoms,  295 
treatment,  296 

after-treatment,  296 
operative  treatment,  296 
Carpus,  injuries  to,  277 
after-care,    292 
diagnosis,   290 
prognosis,  293 
surgical  anatomy,   277 
symptoms,   287 
treatment,  291 

after-treatment,  292 
operative  treatment,  292 
Carrying  angle,  loss  of,    128 
Cartilages,    semilunar,    fractures    and 

dislocations  of,   587 
Cast,  plaster,  for  fracture  of  hip,  546 
in  fracture  of  leg,  649 
in   fracture  of  pelvis,   509 
in  fracture  of  spine,  484 
with  arm  in  abduction,   103 
with  thigh  in  abduction,  548 
with  thigh  in  semiflexion,  548 
Cerebrospinal  fluid,  escape  of,  in  frac- 
ture of   skull,   417 
Chest,  injuries  to, 

(see  Fractures  of  ribs,  459) 
(see  Sternum,  453) 
Clamp,   four-post,    763 
Clavicle,  dislocation  of  inner  end,  5 
after-care,   10 
diagnosis,  7 
prognosis,    10 
surgical  anatomy,  5 
symptoms,  6 


Clavich; — cont'd. 
treatment,  7 

after-treatment,    1 0 
operative!    treatment,    9 
dislocation   of   outer   end,   30 
after-care,  30 
diagnosis,   33 
prognosis,  36 
surgical  anatomy,  30 
symptoms,   32 
treatment,  34 

after-treatment,    36 
operative   treatment,    36 
fracture  of,   11 
after-care,  28 
diagnosis,  22 
prognosis,  29 
surgical   anatomy,    11 
symptoms,   15 
treatment,  22 

after-treatment,  2i8 
operative  treatment,   26 
Coaptation   splints,   for   fracture, 
of  humerus,  115 
of  femoral  shaft,   567 
Cobb's  nasal  splint,  330 
Coccyx,   fracture-dislocations   of,    500 

treatment,  507 
CoUes'  fracture   (see  Radius,  fracture 

of   lower   end,   242 ) 
Coma,  in  head  injuries,  420 
from  alcohol,   433 
from  asphyxia,  435 

belladonna  and  its  alkaloids,  436 
chloral,  435 

hyocyamus  and  its  alkaloids,  436 
lead    poisoning,    436 
morphine,  434 
opium,  434 
phenol,  434 
reflex  causes,  438 
in  abscess  of  brain,  443 
acute  exanthemata,  438 
apoplexy,   440 
cerebral   anemia,   432 
cerebral  congestion,   432 
cerebral  embolism,  440 
cerebral   hemorrhage,   441 
cerebral  meningitis,  443 
cerebral   syphilis,   442 
cerebral   thrombosis,   441 
diabetes,  437 
epilepsy,  439 
feigning,  438 
hysteria,  438 
pneumonia,   438 
ptomaine  poisoning,  435 
shock,  431 
syncope,    431 
tumor  of  brain,  443 


796 


INDEX 


Coma,  in — cnnViJ. 
typlioiil.   4:{S 
Complications    in    t'raiturc    nt    ju'lv  is. 
•     509 
rupture,  of  bhuld.r.  :)l(i,  .")11,  :^\-l 
of  urethra,  50!»,  Tilt) 
Compound  fractures  and  dislocations. 
7«9 
treatment  of,  7 Sit 
Comiirt'ssion    of    luain,    4 In 
Concussion  of  lirain,  407 
Contracture    following.    Colics"    frac- 
ture,  27;') 
dislocation  of  shoulder,  7() 
injury   to  brachial    plexus,   76 
injury    to    nuisculo-spiral,    140 
Volkniaiui's   paralysis,    231 
Contusion    of   brain,   408 
Coracoid   process    {see  Scapula,   frac- 
ture of,  37 ) 
Coronoid  process    (see  Ulna,  fracture 
of  upper   end,    188) 
fracture    of,    complicating    disloca- 
tions of  elbow,  166,  167 
Coxa   vara,   556,   557 
Cradle,    646 

Cranial      nerves,      passage      through 
skull,  344 
symptoms  of  injury  to,   425 
Crepitus   {see  Symptoms  of  region  in 

question ) 
Crookes  tube,  740 

Crushes  of  carpus    {see  Carpus,  inju- 
ries  to,   287) 
of  tarsus,  710 
Cubitus,   valgus    {see  Humerus,   frac- 
tures of  lower   end,    142) 
varus    {see   Hinnerus,    fractures    of 
lower   end,    142) 
Cul)oid,  fractures  and  dislocations  of, 

710 
Cuneiform    (see   Carpus,    injuries   to, 

281,  286,  289) 
Cuneiforms   of   tarsus,   fractures   and 
dislocations  of,   710 


Davison's  method   for  fracture   of   fe- 
mur in  children,  565 
Diagnosis   of, 

dislocations   of,   ankle,   689 
astragalus,  695 
calcaneum,   706 
carpometacarpal  joint,  295 
clavicle,  inner  end,  7 

outer  end,  33 
elbow,    163 
fingers,  315 
hip,  523 


Diagnosis  of,  dislocations — cont'd. 
OS  calcis,   706 
patella,   611 
l>clvis,    505 

[ilialangi's  of   hand,   315 
radius,  head  of,    180 
semihniar  cartilages,  590 
slioulder.   64 
spin.'.   4S:i 

subastragalar  joint.   7lU 
subcoracoid,    of    shoulder,    (i4 
suliglenoid,  of  shoulder,  64 
tarso-mefatarsal  joint,  713 
ulna,    lower   end,   239 
wrist,   290 
fractin-e  of, 

astragalus,  695 
calcaneum,   706 
car])us,  290 
clavicle,    22 
coccyx,    506 
femur,   lower   end,   579 
shaft,  562 
upper  end,  539 
tibula,  lower  end,  666,  679,  689 
shaft,  642 
upper  end,  627 
fingers,   310 
hip,   539 

humerus,  lower  end,  136 
shaft.    111 
upper  end,  95 
inferior  maxilla,  356 
jaw,  lower,  356 

upper,  345 
metacarpals,   300 
metatarsals,  718 
malar,    338 
maxilla,   inferior,  356 

superior,  345 
nasal  bones,  327 
olecranon,    190 
pattdla,   597 
l)elvis,  505 

])halanges  of  hand,  310 
radial  and  ulnar  shafts,  219 
radius,  lower  end,  260 
shaft,  219 
upper  end,  200 
ribs,   462 
scapula,   41 

semi-lunar   cartilages,   590 
spine,   483 

superior  maxilla,  345 
tibia  and  fibiila,  lower  ends,  666, 
679,   689 
shafts,    642 
upper   ends,   627 
ulna,  lower  end,  234 
shaft,   219 


INDEX 


797 


Fibula,  ulna — cont'd. 
upper  end,  li)0 
zygomatic  arcli,  3i88 
in  Colles'  fracture,  200 
in  injuries  to  carpus,  200 
in  Pott's  fracture,  660 
Definitions  and  terms,   725 
Deformity      (see     Symptoms,     under 
fractures   and   dislocations 
of      various      bones      and 
joints) 
Deformity,   garden-spade,   244 
gunstock,  135,  138,  142,  158,  201 
in  Barton's  fracture,  257 
in  Bennett's  fracture,  229,  230 
in  Colles'  fracture,  252-262 
in  dislocation  of  wrist,  262,  287 
in  Pott's  fracture,  664,  665,  666, 

667 
in  Volkmann's  contracture,  230 
Madelung's,  239 
silver-fork,   247,   252-262 
Desault   splint,   645 
DeVilbiss  forceps,  448 
Dislocatio  erecta,  60 
Dislocation      of,       acromioclavicular 
joint,    30 
ankle,   684    {see  Ankle) 
astragalus,  692    (see  Astragalus) 
calcaneum,    703    (see    Calcaneum) 
carpal  bones,  277    (see  Carpus) 
carpo-metacarpal   joint,    294 
cervical  vertebrae,   465    (see  Spine) 
clavicle    (see  Clavicle) 
inner  end,  5 
outer  end,  30 
coccyx,  500    (see  Pelvis) 
costal  cartilages,  460   (see  Ribs) 
cuboid,  710 
cuneiforms,   710 
elbow,   154    (see  Elbow) 
fingers,  314    (see  Fingers) 
head    of   humerus,    44    (see    Shoul- 
der) 
head  of  radius,  177    (see  Radius) 
hip,  515   (see  Hip) 
inferior  maxilla,  376    (see  Maxilla, 

inferior ) 
jaw,  376   (see  Maxilla,  inferior) 
knee,  613    (see  Knee) 
medio-tarsal  joint,  709 
OS  calcis,   703    (see  Calcaneum) 
patella,  609   (see  Patella) 
pelvis,  492   (see  Pelvis) 
phalanges  of  foot,  720    (see  Toes) 
radius    (see  Radius) 

upper  end,   177 
radius    and    ulna,    divergent,     154 

(see  Elbow) 
scaphoid,  710 


Dislocation  of— cont'd. 

semilunar      cartilages,      587       (see 

Sfimilunar    (tartilagcs) 
shoulder,   44    (see  Sliouidcr) 
spine,  465    (see  Spine) 
subastragalar   joint,   099 
sternal  end  of  clavicle,  5 
thumb,  314 
ulna,  lower  end,  237 

upper  end,  175 
wrist,  277    (see  Carpus) 
Drainage,    in    operative   treatment    of 
fractures,   758 
in  treatment  of  compound  fractures 
and  luxations,  790 
Dupuy's  splint  for   fracture  of  lower 

extremity,  581 
Dupuytren's    splint,   668 


E 


Ecchymosis,    in    fracture    of    clavicle, 
21 
humerus,   89,   96 
leg,   640 
olecranon,    190 
skull,  418,  420 
Edmund's  forceps,  364 
Elbow,  dislocations  of,   154 
after-care,   171 
diagnosis,   163 
fracture   complicating,    156 
prognosis,   174 
surgical  anatomy,   154 
symptoms,  156 
treatment,  167 

after-treatment,    171 
operative  treatment,   170 
Embolism,  fat,  642 

Emergency  treatment,   of  fracture  of 
leg,   642 
of  thigh,  563 
Emphysema,    in    fracture    of,    malar 
and  superior  maxilla,  338, 
344 
nasal  bones,  326 
ribs,  462 
Epilepsy,  as  a  cause  of  unconscious- 
ness, 439 
following  fracture  of  skull,  451 
treatment   of,   45 1 
Epileptic     unconsciousness,     differen- 
tiated   from    coma    accom- 
panying     head      injuries, 
439 
Epiphyseal      separations,      considered 
under  fracture  of  bone  in 
question     ( see    Fracture ) 
Epiphysis  of,  acromion,  37 
clavicle,   11 


798 


INDEX 


Epiphysis  of — cont'd. 
loraooid,  38 
femur,    lower   end,   .")70 

upper  end,   ">:U 
humerus,   U)\yer   end,    125 

upper  end,  88 
nu'tiu'iu]  iu    I. ones,   2!I7 
metatarsal  bones,  714 
pelvis,    4!)2 

phalanges  of  fingers,  307 
radius,  lower  end,  251 

upper  end,   1D8 
seapula,   37 
tibia  and   liliula,  lower  ends,  076 

upper  ends,  1)22 
ulna,  lower   end,  232 
upper  end,    180 
Erect   dislocation    of   shoulder,   GO 
Etiology   of, 

dislocation,  of  hip,  520 
inferior  maxilla,  377 
patella,    010 
fracture  of,  femoral  shaft,  560 
U])iier   end,  534 
liunurus,  upper   end,   89 
inferior    maxilla,    350 
malar,   330 
nasal  bones,  325 
patella,  595 
pelvis,    496 

tibia  and  fibula,  shafts,  637 
upper   ends,   624 
Everted    dorsal    dislocations    of    hip, 

519 
Examination    {see   Diagnosis) 
Eacc,   fracture  T   of  bones  of, 
malar,  334 
maxilla,  inferior,  348 

superior,  343 
nasal,  323 
Facial,   artery,   injury   to,   350 

nerve,   injury   to,   350 
Fat  embolism,   042 
Feeding     after     fracture     of     inferior 

maxilla,  375 
Femur, 

dislocation   of   lower   end,   613    {see 
Knee ) 
UDoer  end,  515    {see  Hip) 
fracture   of,   lower   end,   574 
after-care,   584 
diagnosis,  579 
prognosis,   586 
surgical   anatomy,   574 
symptoms,  578 
treatment,   580 

after-treatment,   584 
operative  treatment,  582 
shaft,   558 

after-care,   572 


I'cimir.  sliaft — iniit'd. 
diagnosis,  562 
.•tiology,    560 
in  cliildren,  508 
in   ncw-lxirn,   5li8 
prognosis,    573 
surgical    anatomy,   558 
symptoms,   501 
trt'atnu'nt,   503 

after-treatment,    572 
operative   treatment,   569 
u|)p«'r    end,    531 
after-care,   552 
diagnosis,   539 
in    <'hildren,    555 
])rognosis,    555 
surgical   anatomy,   531 
symi)toms,   537 
treatment,   542 

after-treatment,  552 
operative  treatment,  550 
Fingers,    base-ball,    309 
Fingers,  dislocation  of,  314 
after-care,   318 
diagnosis,   315 
prognosis,    319 
surgical    anatomy,   314 
symi)toms,   317 
treatment,    3 1 7 

after-treatment,    318 
()I)erative   treatment,   318 
fractures  of,  307 
after-care,    312 
diagnosis,   310 
prognosis,    313 
surgical  anatomy,  307 
svmptoms,   308 
treatment,  310 

after-treatment,    312 
operative  treatment,  311 
Fissure  of   Rolando,    401 
Flap,  osteoplastic  of,  skull,  447 

of  si)ine,  488 
Flat-foot,  traumatic,  673,  70^ 
Forceps,    DeVilbiss,   448 

Edmund's,  364 
Forearm,  fracture  of  shafts  of  bonea 
of,    204     {see    Radial    and 
Ulnar  shafts) 
Four-])ost  clamp,  763 

Freeman's,   764 
Fourtailed  bandage,  358 
Fracture  of, 

acetabulum,   499    {see  Pelvis) 

complicating  luxation  of  hip,  582 
acromion  process,  40   {see  Scapula) 
accompanying    upward    luxation 
of  shoulder,  51 
anatomical  neck  of  humerus,  90 
astragalus,   692 


INDEX 


799 


Fracture  of,  astragalus — cont'd. 
after-care,   6i)8 
diagnosis,  ()i)5 
prognosis,   ()i)8 
surgical   anatomy,   692 
symptoms,   6i)4 
treatment,  605 

after-treatment,  6!)8 
operative   treatment,    607 
Barton's,   251 
Bennett's,   299 
calcaneum,  703 
after-care,   707 
diagnosis,    706 
prognosis,   708 
surgical   anatomy,   703 
symptoms,   705 
treatment,   706 

after-treatment,  707 
operative   treatment,   706 
carpal  bones,  277 
after-care,   292 
diagnosis,  290 
prognosis,   293 
surgical  anatomy,  277 
symptoms,   287 
treatment,   291 

after-treatment,  292 
operative  treatment,  292 
clavicle,    1 1 
after-care,   28 
diagnosis,  22 
prognosis,  29 
surgical  anatomy,   11 
symptoms,  15 
treatment,    22 

after-treatment,  22 
operative    treatment,    26 
coccyx,  500    {see  Pelvis) 

treatment,   507 
coracoid  process,  38    {see  Scapula) 
cuboid,  710 

after-care,   712  . 
prognosis,  712 
surgical   anatomy,   710 
treatment,   710 

after-treatment,   712 
operative  treatment,  712 
cuneiforms,   710 

treatment,   710 
femur,   lower   end,   574 
after-care,   584 
diagnosis,  579 
prognosis,   586 
surgical   anatomy,   574 
symptoms,   578 
treatment,  580 

after-treatment,  584 
operative   treatment,   582 
shaft,    558 


J^Yacture   of,    fc^iiinr,    shaft — cont'd. 
after-care,  572 
diagnosis,  562 
etiology,  560 
in  children,  568 
in  the  nevv-I)orn,  56i8 
]jrognosis,    573 
surgical   anatomy,   558 
symptoms,   5(51 
treatment,  5()3 

after-treatment,  572 
operative   treatment,    560 
upper  end,  531 
after-care,   552 
diagnosis,    539 
etiology,   534 
in    children,    555 
prognosis,    555 
surgical  anatomy,  531 
symptoms,    537 
treatment,   542 

after-treatment,  552 
operative   treatment,    550 
fibula    {see  Tibia  and   Fibula) 
lower   end,   675 
shaft,    634 
upper    end,    620 
fingers,   307 
after-care,  312 
diagnosis,   310 
prognosis,  313 
surgical   anatomy,   307 
symptoms,   308 
treatment,  310 

after-treatment,    312 
operative   treatment,   311 
forearm,  bones  of,   184    {see  Radius 

and  Ulna) 
hip,  531    {see  Femur) 
humerus,    anatomical   neck   of,    90 
lower   end,   120 
after-care,  151 
diagnosis,   136 
prognosis,  152 
surgical    anatomy,    120 
symptoms,    128 
treatment,  143 

after-treatment,    151 
operative   treatment,    148 
shaft,    108 

after-care,  119 
diagnosis,  111 
prognosis,  119 
surgical  anatomy,  108 
symptoms,  110 
treatment,  113 

after-treatment,  119 
operative    treatment,     116 
upper   end,   82 
after-care,   106 


800 


INDEX 


Kraftuii'    of.    huiiu-nis,    upper    t'lul — 

COtlt'll. 

diajrnosis,    95 
pni'inosis.    107 
suruiial  anatomy,  82 
symi)toms,    S!t 
tri'atiiu'ut.    !17 

aftiT-trcatiiuiit.    KMI 
oi)(.'rati\  (■    trcatiiifiit.    MM 
isc'liium,    r>(t(i 
malar,    H:M 

aftor-iarf,    342 
cliafiuosis,   ;i^8 
etiology,   •VM't 
prognosis,    342 
suryiral    aiiatt)my.   3.34 
svmptoms,   33(( 
treatment.    331) 

after-treatment,  342 
ujierative   treatment,   340 
maxilla,  inferior,  348 
after-care,   375 
diajinosis,  35t> 
etiology,    350 
|irognt)sis,    375 
surgieal  anatomy,  348 
symptoms,    351 
treatment,  357 

after-treatment,    375 
oi)erative   treatment,   373 
superior,    343 
after-care,   346 
diagnosis,    345 
prognosis,  347 
surgical   anatomy,    343 
symiJtonis.  344 
treatment,  345 

after-treatment,    346 
operative   treatment,   346 
metacarpals,  207 
after-care,  306 
diagnosis,   300 
prognosis,  306 
surgical  anatomy,  397 
symi>t()ms,   2!M) 
treatment.    301 

after-treatment,  306 
operative  treatment,  305 
metatarsals,   714 
after-care,    718 
diagnosis,    718 
prognosis,    710 
surgical   anatomy,   714 
sym])toms,   716 
treatment.  718 

after-treatment,  718 
operative   treatment,   718 
nasal  hones,  323 
after-care,   332 
diagnosis,   327 


I'racture    of.    nasal    hones — cout'd. 
etiology,   325 
prognosis,  333 
surgical   anatomy,  323 
svniptoms,   325 
treatment,    320 

after-treatnu'iit.  332 
o|ierative    treatment,    331 
iia\icular.    71i' 

treatnH'ut.   7  U' 
nose,  323    (see  Nasal  hones) 
olecranon,    185 

OS   calcis,    703    (sec    Calcaiieum) 
patella.  504 
after-care.    605 
diagnosis.    507 
.tiniugy.    505 
])rognosis.  tiOS 
sui'gical    anatomy.    504 
symjitoms.    505 
ti'catment,    508 

after-treatment,    605 
oi)erative   treatment,   600 
pelvis,   402 

(•nmi)lications,   500 

injury    to,    hladder,    510 
pelvic   viscera,   509 
urethra,   509 
vessels,  509 
diagnosis,  505 
etiology,    496 
pathology,  496 
surgical    anatomy,   492 
symptoms,    497 
treatment,    507 

of  comjjlications,   510,  511 
])lialanges  of   foot,   720 
])rognosis,  721 
surgical   anatomy,    720 
symjjtoms,  720 
treatment,   720 
])]ialanges  of  hand,  307 
after-care,    312 
diagnosis,   310 
prognosis.    313 
surgical  anatomy,  307 
symptoms,    308 
treatment,   310 

after-treatment.    312 
operative  treatment,  311 
radius,   lower  end,  242 
after-care,  271 
Colles'    fracture,    242 
diagnosis.   260 
])rognosis,    273 
surgical    anatomy,    242 
symptoms,   252 
treatment,  264 

after-treatment,    271 
operative  treatment,  269 


INDEX 


801 


Fracture  of — cont'd. 
shaft,  204 

aftor-care,  228 
diagnosis,  219 
prognosis,  229 
surgical  anatomy,  204 
symptoms,  200 
treatment,    220 

after-treatment,    228 

operative   treatment,   225 
upper    end,    197 
after-care,  202 
diagnosis,  200 
prognosis,   203 
surgical  anatomy,  197 
symptoms,    199 
treatment,  200 

after-treatment,   202 

operative  treatment,   202 
ribs,    459 

after-care,  463 
diagnosis,  462 
emphysema  in,  462 
prognosis,  464 
surgical  anatomy,  459 
symptoms,  461 
treatment,    462 

after-treatment,  463 
scaphoid,    710 
scapula,    37 

acromion  process,  40 
after-care,  43 
coracoid   process,   40 
diagnosis,  41 
prognosis,    43 
surgical  anatomy,  37 
symptoms,  40 
treatment,   42 

after-treatment,    43 
semilunar    {see  Carpus) 
semilunar  cartilages,  587 
after-care,    592 
diagnosis,   590 
prognosis,    593 
surgical  anatomy,  587 
symptoms,   588 
treatment,    591 

after-treatment,  592 

operative   treatment,   591 
skull,  391    (see  Skull,  fractures  of) 
diagnosis,   427 

differential,    429 
prognosis,    449 
surgical    anatomy,    392 
symptoms,   411 
treatment,   444 

operative  treatment,  447 
spine,  465 

after-care,  490 


Fracture  of,  spine, — cont'd. 
diagnosis,  483 
])rogno8i8,   491 
surgical  anatomy,  465 
symptoms,   473 

cervical   region,   481 
lumliar  region,  482 
tlioracic    region,    482 
treatment,    484 

after-treatment,    490 
operative   treatment,   486 
sternum,   453 
after-care,   458 
prognosis,   458 
surgical  anatomy,  453 
treatment,  456 

after-treatment,  458 
operative   treatment,   457 
tibia  and  fibula,  lower  ends,  675 
after-care,    683 
diagnosis,  679 
prognosis,  683 
surgical  anatomy,  675 
symptoms,  675 
treatment,   681 

after-treatment,    683 
operative   treatment,   682 
shafts,  634 

after-care,    654 
diagnosis,  642 
etiology,  637 
prognosis,   657 
surgical  anatomy,  634 
symptoms,    638 
treatment,   642 

after-treatment,  654 
operative   treatment,    650 
iipper  ends,  620 
after-care,    631 
diagnosis,  627 
etiology,  624 
prognosis,    633 
surgical    anatomy,    620 
symptoms,  625 
treatment,  627 

after-treatment,  631 
operative  treatment,   629 
ulna,  lower  end,  232 
after-care,  235 
diagnosis,  234 
prognosis,    236 
surgical  anatomy,  232 
symptoms,   234 
treatment,   235 

after-treatment,    235 
operative   treatment,   235 
shaft,  204 

after-care,   228 
diagnosis,   219 


802 


INDEX 


Fnu-turi'  of,  ulna,  sliaft— <v)h/'(7. 
proiiiuisis.   "i-ill 
t*urf:ii'al  anatomy,  201 
synii>tonis,   "itXi 
tii-atnu-nt,  -i-iO 

afti'i-tioatnu-nt,  22S 
operativi'   treatment,    22') 
u])|)i'r  iiul    (oli'i-ranon  I .    IS.") 
aftiT-eari',    !!•.') 
diagnosis,    VM) 
[irognosis,    l!Mi 
surgieal  anatomy,   185 
symptoms,    ISS 
treatment,    MX) 

after-treatment,    1 05 
operative   treatment,    I'-'l 
zygomatic   areli,    :VA-i    {sec   Malar) 
Fraeture-box,  t)43 

as  double  inclined   plane,   r)S2 
use  of,  t)-44 
Fractures,    compound,    treatment    of. 
7sn 

open   treatment  of,   7o4 

absorbable    suture    material,    768 
asepsis    in,    7.ib 

cautions   in   closing   wound,   758 
drainage,    758 
the  four-post  clamp,  763 
the  Lane  plate,  700 
use  of  screws,  nails,  etc.,  759 
Freeman's  clamp,  704 

G 

German  base  line,  400 

Gerster's  turn  buckle,  702 

Glycosuria    following    head    injuries, 
429 

Goldthwaite's  splint,   311 

Grafting  of  bone,  771 

Gun-stock  deformity, 

in  dislocation  of  elbow,  158 
in    fracture   below   elbow,   201 
in  fracture  of  humerus,  12:8 

H 

Hammond's  %vire  splint,  372 
Head   injuries,   391    {see   Skull,   frac- 
ture of) 
compression,  410 
concussion,  407 
contusion,  408 
laceration,  409 
Heath    splint,    for    fracture    of    man- 
dible, 363 
Heel,    fracture    of,    703     (see    Calca- 

neum ) 
Hematoma  of  scalp,  382 
Hematomvelia,    in    fracture    of    spine, 
479 


llcniatnrrliarlus.   in    tracturt'  of  spine, 

47'.l 
Ibiiiatvuia.   in   fract\ire  of  pelvis,  509, 

.-)ll 
ll.'inorrliage.    beneath    skin     (see    Ec- 
chymosis  | 
into  sjiinal   cord,   479 
intracranial,   397 
meningeal,  of  cord,  579 
subdural,    397 
Hip,    dislocation    of.    515 
after-care,    530 
diagnosis,   523 
etiology,  520 
prognosis,    530 
surgical   anatomy.   515 
symptoms,   520 
treatment,   524 

after-treatment,   530 
operative   treatment,   529 
types,  519 
fracture    of,    531     {see   Neck    of    fe- 
mur ) 
after-care,   552 
diagnosis,    539 
etiology,  534 

injuries  to  femoral  neck  in  chil- 
dren, 555 
prognosis,  555 
surgical   anatomy,   531 
symptoms,   537 
treatment,  542 

after-treatment,  552 
operative  treatment,  550 
Hodgen's  si)lint,  582 
Hook,  ^IcBurney's,  72 
Humerus,     dislocation     of,     44      (see 
Shoulder,    dislocation    of) 
fracture  of,  lower  end,   120 
after-care,   151 

crescentic   fracture,    121,    123 
diagnosis,    130 
external  condyle,  130 
external    epicondyle,    129 
internal  condyle,   131 
internal  epicondyle,    131 
])rognosis,   152 
surgical  anatomy,   120 
svmi)toms,    12S 
T-fracture,   134 
transverse  fracture,    131 
treatment,   143 

after-treatment,   151 
operative  treatment,   148 
shaft,    108 

after-care,  119 
diagnosis.  111 
nnisculo-spiral    nerve    in,    108, 

117,  119 
prognosis,   119 


INDEX 


803 


Humerus,  fracture  of  shaft — cont'd. 

aurfiical  anatomy,   108 

symptoms,   110 

treatment,   113 

after-treatment,   11!) 
operative   treatment,    1 1 6 
upper   end,  82 

after-care,   106 

anatomical  neck,  83 

diagnosis,    95 

dislocation     of    humeral     head 
complicating,   72-76 

etiology,  89 

fractvire  of  tuberosities,  85 

prognosis,    107 

separation  of  epiphysis,  88 

surgical   anatomy,   82 

surgical  neck,   87 

symptoms,   89 

treatment,   97 

after-treatment,  106 
operative   treatment,    104 
Hysterical  unconsciousness,   438 


Iliac  dislocation  of  hip,  517 

everted,    519 
Iliopectineal  dislocation  of  hip,  518 
Ilium,  fracture  of,  498    (see  Pelvis) 
Inclined  plane,  double,  580,  581,  582 

in  fracture  of  thigh,  564 
Internal  right-angle  splint,  146 

with   traction,    146 
Intracranial  sinuses,   399 
Ischium,  fracture  of,  500   (see  Pelvis) 


Jaw,  lower    (see  Maxilla,  inferior) 
dislocation  of,  376 
fracture  of,  348 
upper,  fracture  of,  343 

K 

Kingsley's  splint,  361 
Kocher's  method  of  reducing  disloca- 
tions of  shoulder,   66,   67 
Knee,   dislocation   of,   613 
prognosis,   619 
surgical  anatomy,  613 
symptoms,   616 
treatment,  617 

after-treatment,   619 
operative  treatment,   618 


Laceration  of  brain,  409 


Laminectomy,   487 
Lane's  l)one  drill,  760 
))one    plates,    766 

Sherman's   modilication   of,   765 
Leg,     fractures     of     bones     of,     lower 
ends,   675    (see   also  Pott's 
fracture    and    ankli;) 
after-care,     (i83 
diagnosis,    679 
prognosis,   683 
surgical    anatomy,    ()75 
symptoms,   675 
treatment,   681 

after-treatment,  683 
operative   treatment,   682 
shafts   of,    634 
after-care,    654 
etiology,    637 
diagnosis,    642 
prognosis,    657 
surgical  anatomy,  634 
symptoms,    638 
treatment,  642 

after-treatment,  654 
operative   treatment,    650 
upper   ends  of,   620 
after-care,   631 
diagnosis,  627 
etiology,    624 
prognosis,  633 
surgical  anatomy,  620 
symptoms,   625 
treatment,   627 

after-treatment,   631 
operative  treatment,   629 
Ligaments,   acromio-clavicular,   30 
capsular,   of   hip,    515 

of  shoulder,  44 
of  ankle,  685 
of  clavicle,  inner  end,  5 

outer  end,  30 
of  elbow,   154 
of  hip,  515 
of  knee,  613,  614 
of  shoulder,  44 
radioulnar,   lower,    237 

upper,   177 
Y-ligament  of  Bigelow,  516 
Lothrop's    operation    in    fractures    of 

malar,  340 
Lumbar     puncture     in     fracture     of 

skull,  449 
Lung,    puncture    of,    in    fracture    of 

ribs,  462 
Liixatio  ereeta,  61 
Luxations    (see    Dislocations) 

M 
Madelung's  deformity,  239 


804 


INDEX 


^lalar    bone,    fractiiro   of,    334 
after-care,  342 
(lia>;nosis,  33S 
etiolopv,  33(i 
proiiiio'sis.  34-2 
sin\i:ii-al   anatomy,  334 
syiiiptoms.    33t) 
tn-atiiiciit.   33!) 

a ftcr-treatment,  342 
oiH'rative  treatment,  340 
Mandilile    {sec    Maxilla,    inferior) 
^lassage    (see   After-treatment) 
Matas    splint,    3(12 
Maxilla,    inferior. 

dislocation   of,   37(i 
etiolo-y,    377 
iu'diznosis.    37S 
siir<:ieal  anatomy,  37t) 
symjitoms,    377 
treatment,   377 

after-treatment,  378 
fracture  of,  348 
after-care,  375 
diagnosis,  3o0 
]>rogTiosis,  375 
surgical  anatomy,  348 
symptoms,  3.51 
treatment,   357 

after-treatment,  375 
operative   treatment,    373 
sui)erior,   fracture   of,   343 
after-care,  34(5 
diagnosis,   345 
prognosis,  347 
surgical  anatomy,  343 
sym])toms,   344 
treatment,    345 

after-treatment,    346 
operative   treatment,   346 
McBurney's  hook,  72 
Measurements  in    {see  Diagnosis) 
fracture  of  femur,  539 
of  humerus,  0(i 
Medio-tarsal     joint,     dislocations     of, 
70!) 
surgical  anatomy,   7ii'.) 
treatment,  70!) 
Meninges,  of  brain,   3!)5 

vessels   of,   306 
-Meningitis,    differentiated    from    frac- 
ture  of   skull,   443 
^letacarpal     bones,     dislocations     of, 
204      {see     Carjio-metacar- 
pal    luxations) 
fractures    of,    207 
after-care,    306 
diagnosis,   300 
]n-ognosis,    306 
surgical   anatomy,   297 
symptoms,  299 


Metacarpal      bones,      frai'tures      of — 
cont'd. 
treatnu-nt,   301 

after-treatment,  306 
operative  treatment,  305 
Metal     numbers    for    marking    X-ray 

plates,    704 
Metatarsal      bones,      dislocations     of, 
713    (see  Tarsometatarsal 
luxations) 
fractures  of,   714 
after-care,    7 1 8 
diagnosis,   718 
prognosis,   71!) 
surgical   anatomy.    714 
symptoms.   716 
treatment,  718 

after-treatment,  718 
oi)erative   treatment,    718 
]Middledorf   triangle,    102 
Mohr's  tigure-of-eight  bandage,  25 
Musculo-si)iral    nerve    in    fractures   of 
liumerus.    108,    117,    119 
N 
Nasal  bones,   fractures  of,   323 
after-care,  332 
diagnosis,    327 
etiology,  325 
prognosis,  333 
surgical   anatomy,    323 
sym])toms,  325 
tr(>atment,   329 

after-treatment,  332 
operative  treatment,  331 
Navicular  of  tarsus,  710 
prognosis,  712 
surgical    anatomy,    710 
treatment,  710 

after-treatment,    712 
operative   treatment,    712 
Neck,     anatomical,     of     humerus,     83 
(see   Humerus) 
of  femur,   532,  537    {see  Femur) 
of  sca])ula,  40    {see  Scapula) 
surgical,    of    humerus,    87,    02    {see 
Humerus) 
Neck,    fractures    of.    465     {see    Spine, 

fracture-dislocations    of) 
Nelaton's  line,   533,   534.  539 
Nerves,  cranial,  in  fracture  of  skull, 
394 
exists   through   l)ase,   394 
s>'m])toms  of  injury   to,   425 
Nichols  traction  ap])aratus,  569 
Nose,    fracture    of,    323     (see    Nasal 
bones) 

0 
Olecranon,     fracture     of,      185      (see 
Ulna) 


INDEX 


805 


Olecranon,  fracture  of — cont'd. 
after-care,   l!t5 
complicating     luxations     of     elbow, 

16G 
diagnosis,   100 
prognosis,   196 
surgical   anatomy,    185 
symptoms,   188 
treatment,   190 

after-treatment,    195 
operative  treatment,  191 
Oliver's    method    of    wiring    jaws    to- 
gether, 366 
Operative     treatment     of     compound 
fractures        and        (Lsloca- 
tions,  7^9 
Operative  treatment, 

of  dislocations  of  ankle,  690 
astragalus,  697 
caleaneum,  706 
carpal  bones,  292 
carpometacarpal    joint,    296 
clavicle,  inner  end,  9 

outer  end,  36 
elbow,  170 
fingers,  318 
hip,    529 
OS  calcis,  706 
patella,  611 

phalanges  of  hand,  318 
radius,  head  of,  181 
scmihmar  cartilages,  591 
shoulder,  71 
spine,  486    (see  Spine) 
subastragalar  joint,  701 
ulna,  lower  end,  240 

upper   end,    176 
wrist,  292 
in  fractvire  of,  astragalus,  697 
caleaneum,   706 
carpus,   292 
clavicle,  26 
coccyx,  508 
cuboid,    712 
cuneiforms,  712 
femur,  lower  end,  562 
shaft,  569 
upper    end,    550 
fibula,  lower  end,  651,  682,  690 
shaft,    650 
upper    end,    629 
fingers,  311 
hip,  550 

humerus,  lower  end,   148 
shaft,    116 
upper  end,    104 
jaw,  lower,  373 

upper,  346 
malar,  340 
maxillfi,  inferior,  373 


( >|)erative  treatment,   in    fracture  of — 
cont'tl. 
sui)erior,   346 
metacai'iials,  305 
metatarsals,    718 
nasal   bones,   331 
olecranon,    191 
OS   calcis,    706 
])atella,  600 

phalanges   of   hand,   310 
radial   and  ulnar   shafts,   225 
radius,    lower   end,   '^69 
shaft,    225 
Ujijjer  end,   202 
scaphoid,    712 
semilunar   cartilages,  591 
skull,   447 
spine,  486 
sternum,  457 

tibia  and  fibula,  lower  ends,  682 
shafts,  650 
upper  ends,  629 
ulna,   lower  end,  235 
shaft,  225 
upper  end,  191 
zygomatic   arch,   340 
in  Colles'  fracture,  269 
in  Pott's  fracture,   671 
Os   calcis,   fractures   and   dislocations 
of,  703 
after-care,  707 
diagnosis,  706 
prognosis,  70S 
surgical  anatomy,  703 
symptoms,  705 
treatment,  706 

after-treatment,   707 
operative    treatment,    706 
Osgood-Penhallow  splint,  102 
Os    magnum,    fractures    and    disloca- 
tions of,  277    (see  Carpus) 
Osteitis    of    carpus    following    Colics' 

fracture,    274 
Osteogenesis  imperfecta,   732,   733 


Packing  of  nasal  cavities  in  fracture 

of  nose,   329 
Pad,  axillarv  in  fracture  of  humerus, 

98,   99,    101,    114 
Passive     motion     after      (see     After- 
treatment  ) 
Colles'  fracture.  272 
dislocation  of,  elbow,   172 
fingers,   381 
shovilder,  79 
thiunb,    381 
fracture  of,  clavicle,  29 
olecranon,  195 
patella,  606 


806 


INDEX 


Passive  motion  after — cont'd. 
injuries  to  earpus,  2!>2 
Pott's   fnutnrc.  ()73 
Patella.  disl.H-atipn   of.  (iOO 
after-iare.  y\\l 
diagnosis.  (11 1 
etiolojiy,    (ilO 
prognosis,  1)12 
surgical   anatomy.  (J09 
sym])tonis,  010 
treatment.   Oil 

after-treatment.  612 
operative   treatment,   Oil 
fracture  of,   .)!t4 
after-eare.   005 
diagnosis,  iiOT 
etiology,  ;>!15 
prognosis,  608 
surgical  anatomy,  504 
symptoms,  505 
treatment,  508 

after-treatment.   005 
operative  treatment,  600 
PatholoLnf    fractures.    72S-7.'?:{ 
Pelvis,    fracture-dislocations    of,    492 
diagnosis,    505 
etiology,  400 
patholoijy,  406 
surgical   anatomy,    402 
symptoms,    407 
treatment,    507 

of   complications,    510,    511 
of  rupture  of  bladder,  511 
of   rujiture   of   urethra,   510 
Penliallow,    Osgood-Penhallow    splint. 

102 
Perineal  dislocation  of  hip,  518 
Phalanges,  of  foot,  72f)   {see  Toes) 
of  hand    {see  Fingers) 
dislocations  of,  314 
fracture  of,  307 
Plate,  Lane's,   700 

Plaster  of  Paris,  use  of  in  fractures 
of   femur,   546,   508 
of  hip,  546 

of  humerus,  100,  103,  147 
of   leg,    64S 
of  metacarpals,  305 
of  metatarsals,   718 
of  pelvis,   508 
of  spine,  484 
Pneumonia     following     fractures     of 
hip,   542 
of  rihs.   404 
Pott's  fracture.   050 
after-care,  673 
diagnosis,  060 
]iroernosis,  073 
surgical  anatomy,  659 
symptoms,  664 


Pott's  fracturi^ — cont'd. 
treatnu-nt.  008 

after-treatment.  073 
ojierative    treatment,    671 
Prognosis,    in    dislocations    of, 
ankle,  001 
astragalus,  608 
calcaneum,   708 
carjial  hones,  203 
cari)o-metacar|)al   joint,  206 
clavicle,    inner   end,    10 

outer  end,  36 
cuboid,  712 
elbow,  174 
fingers,   310 
hip,  530 
jaw,  378 
knee.   (ilO 
mandible.    378 
maxilla,  378 
OS  calcis.  708 
l^atella.    612 
phalaniies  of  foot.  721 

of   hand.    310 
radius,   head   of.    183 
semilunar  cartilages,  503 
shoulder.    80 
spine.    401 

subastragalar    joint.    702 
ulna,   lower   end.   241 

\il)])er  end,   176 
fracture   of. 

astragalus,  60S 
calcaneum.  708 
carpus.    203 
clavicle,   29 
cuboid.  712 
cuneiforms.   712 
femur,  lower  end.  580 

shaft,  573 

upper    end,    555 
fibula,    lower   end.   673,   ()83.   001 

shaft.   057 

upper    end.    033 
fingers.    313 
hip.    555 
Imnierus.    lower    end.    152 

shaft.    110 

ujiper   end.   107 
inferior  maxilla,   375 
jaw,  lower,  375 

upper,   347 
malar.   342 
maxilla,    inferior.   375 

superior.  347 
metacarpals.  300 
metatarsals,  719 
nasal   bones.   333 
olecranon.    196 
OS   calcis.   708 
patella,  608 


INDEX 


807 


Prognosis,  fracture  of — cont'd. 
phalanges  of  foot,  721 

of  hand,   312 
radial  and  ulnar  shafts,  22f) 
radius,  lower   end,   2.']6 
shaft,    229 
upper  end,  203 
ribs,   464 
scaphoid,   712 
scapula,  43 

semilunar  cartilages,  593 
spine,  491 
sternum,  458 
superior  maxilla,  347 
tibia  and  fibula,  lower  ends,  6S3 
shafts,  657 
upper  ends,  633 
ulna,  lower  end,  236 
shaft,  229 
upper  end,    196 
zygomatic  arch,   342 
of   Colles'   fracture,   236 
of  Pott's  fracture,  673 
Pubic  dislocation  of  hip,  573 
Pulse,  in  fracture  of  skull,  422 
Puncture,     lumbar,     in     fracture     of 

skull,  449 
Punctvire  of  lung  in  fracture  of  ribs, 

462 
Pupils,    reaction    of,    in    fracture    of 
skull,   423 
in  various  types  of  coma   {see  Dif- 
ferential diaonosis  in  frac- 
ture  of   skull,   429) 

Q 

Qualimeter,  Bauer's,  746 

E, 

Rachitis    as    cause    of    fracture,    732, 

733 
Padio-chronometer,   746 
Padio-ulnar    ligaments,    lower,    237 

upper,  177 
Padius,  dislocation  of  upper  end,  177 
after-care,    182 
diagnosis,  180 
prognosis,    183 
surgical   anatomy,    177 
symptoms,  178 
treatment,  180 

after-treatment,   182 
operative   treatment,    181 
fracture   of,    lower    end,    242 
after-care,    271 
diagnosis,  260 
prognosis,   273 
surgical   anatomy,   242 
symptoms,  252 


Padius,  fracture  of— cont'd. 
treatment,  264 

after-treatment,  271 
operative  treatment,  269 
of  shaft,  204 
after-care,  228 
diagnosis,    219 
prognosis,  229 
surgical   anatomy,   204 
symptoms,   206 
treatment,  220 

after-treatment,    228 
operative   treatment,    225 
of   upper   end,    197 
after-care,  202 
diagnosis,  200 
prognosis,  203 
surgical  anatomy,   197 
symptoms,    199 
treatment,   200 

after-treatment,  202 
operative  treatment,  202 
Heduction   of    (see  Treatment) 
Reflexes  in    {see  Symptoms) 

coma  from  various  causes,  429   {see 
Differential     diagnosis     of 
fracture  of  skull) 
fracture   of   skull,   423 
of    spine,    480 
Respiration    in    coma,    from    various 
causes,    429 
in  fracture  of  ribs,  461 
of  skull,   422 
of  sternum,  426 
Reversed   Colles'   fracture,   244 
Reversed  Pott's  fracture,  664 
Ribs,  fractures  of,  459 
after-care,  463 
diagTiosis,   462 
prognosis,   464 
surgical  anatomy,  459 
symptoms,  461 
treatment,  462 

after-treatment,  463 
Rolando,  fissure  of,  401 
Rijntgen   ray  in   diagnosis   and   treat- 
ment     of      fractures      and 
luxations,  735 
Rose  portable  coil,  738,  739 
Ruth-Maxwell   method  in   fracture   of 
hip,   545 


S 


Racro-iliac  synchondrosis,  504 
Sarcoma  as  cause  of  fracture.  730 
Sayre's  dressing    (modified)    in  dislo- 
cations of  clavicle,  9 

in  fracture  of  clavicle,  24 

in  fracture  of  scapula,  42 


808 


INDEX 


Scalp  wounds,  .S7!1 
aftiT  raif,  :?!)() 
coinplicatioiis.  ;iS4 
|iatlii>l()>;y,  ."JS-i 

ri'(.-oj:iutioii  <>f  coinplications,  .SS!1 
seqiU'hv,  .SS4 
surgical  anatomy.  :57'.' 
syiniitonis,  :iS2 
treatment,  SSf) 

closure  of  wound,  389 
control  of  lu-niorrhage,  385 
lirevention  of  infection,  388 
varieties.  3S:?,   384 
Sea|ilioid    of    carpus,    dislocations    of, 
•2Sti 
"divided."   283 
fracture  of,  280 
Scai)ula.  fracture  of,  37 
after-cari',  43 
diagnosis,  41 
])rouiiosis,  43 
surgical   anatomy,  37 
symptcmis,  40 
treatment,  42 

after-treatment,  43 
Sciatic  dislocation  of  hip,  517 
Screw-])lato,  Author's,  550,  551 
Semihuiar,  fracture  of    {see  Carpus) 
Seniihuiar    cartilages,    fractures    and 
dislocations  of,  587 
after-care,  502 
diagnosis,  500 
prognosis,   503 
surgical   anatomy,   597 
symptoms,  588 
treatment,  501 

after-treatment,  502 
operative   treatment,   501 
Separations,      ejiiphyseal,      considered 
inider   fracture   of  lione  in 
(jiu'stion    {sec   Fractinc) 
Slieriiian's      modilication      of      Lane's 
])late.   7()5,   7()(t 
tap-screw.  7()() 
Shoulder,  dislocation  of,  44 
after-care.    70 
diagnosis.   (>4 
etiology,  51 

tiiuture  complicating,  72 
old  dislocations,  77 
])rognosis,  80 
recurrent  dislocations,  77 
surgical  anatomy,  44 
sym])toms,  52 
treatment.  (56 

after-treatment.    70 
horizontal  traction    in,  60 
Koclier's  method    in,  Gfi,  67 
operative  treatment,  71 
Stimson's  method  in,  69 


Shoulder,  dislocation   of — cotit'd. 

tyi.es.  40 
Silver   fork  deformity.  252-259 
Skull,  fractiu-es  of.  301 
diagnosis.   427 

(lilVerential    from. 

abscess  of  hrain.   443 
ah'oliolic   coma,    433 
aiio])lectiform   and  epilcidit'orm 

convulsions.    443 
ai)oi)lexy,   440 
aspliyxia  from  gas.  435 
cerebral   anemia.  432 
cerebral    congestion,   432 
cerebral    embolism,   440 
cerebral    hemorrluige,    441 
cerel)ral   sypliilis,  442 
cerebral   thrombosis,   441 
coma    of    acute    infections.    438 
diabetic  coma,  437 
ei>i]epsy.    430 
epileptiform   attacks,   443 
feigning,   438 
hysteria,  438 

poisoning    bv,    belladonna,    431) 
alcohol,   433 
chloral,  435 
hvocyamus,  436 
lead,"  436 
opiixm,  434 
phenol.  434 
ptomaines,   435 
shock,  431 
syncope,  431 
tumor  of  brain.  443 
uremic  coma,  436 
etiology,  404 

mechanism  and  pathology,  405 
fracture  by,  hending,  405 
bursting,  405 
contre  coup,  40i; 
giuishot  fractures.   407 
]irognosis,  440 
surgical  aiuvtomv,  302 
l)ones   of   skull,    302 
cortical  centers,  399 
formation  of,  base,  303 

vault,  302 
membranes  of  brain,   305 

vessels  of,  306 
meningeal  vessels,  396 
sinuses,  intracranial,  390 
symptoms,   411 
aphasias,  424 
classification  of,  412 
compression.  410 
concvission,   407 
contusion.  408 

cranial  nerve   symptoms,   425 
depressions  in  hone,  413 


INDKX 


809 


8kiill,       frai'tnrcH      of,      syin|)t()ms — 
cont'd. 
(IcnMations   in  eyes,   422 
clistvirht'd  psychic  function,  42  4 
cccliyniosis,  4 IS 
empliyscina,  420 
escapt'  of   Mood  and   brain,  417 
general    llaccidity,  421 
headache,   421 
laceration,  40!) 

late    symptoms   and   secpiela-,   4r)n 
ciironic  headache,  451 
disturbances  in  hcarin<>-,   4.')1 
e])ilepsy,  451 
psychic  changes,   452 
vertigo,   451 
vomiting,  451 
weakness  of  intellect,  452 
localizing,  423 
mobility  and  crepitus,  413 
pain  in  region  of  fracture,  413 
pulse  in,  422 
pupillary   reactions,   423 
rellexes,    deep,    of   two   sides,   423 
respiration,  422 
temperature,  422 

of  two  sides,  424 
unconsciousness,  420 
vomiting,   420 
vertigo,  421 
treatment,  444 

catheterization.   445 
electric  heat  blanket,  444 
hot  water  bottles,  444 

dangers  of,  444 
nasal  and  oral  cavities,   446 
operative  treatment,  447 
elevation  of  fragments,  447 
osteoplastic  flap,  448 
sedatives,  445 
stimulation,  445 
the  ear,  446 
Smith,  R.  E.,  splint,  646 
Spine,   fracture-dislocations  of,   465 
after-care,  4!)0 
diagnosis,  483 
prognosis,  401 
surgical  anatomy,  465 
symptoms,  473 
treatment,  484 

after-treatment,  400 
operative   treatment,   486 
Splints, 

ambulatorv     pneumatic,     554,     585, 

655 
Cabot  wire  splint,  580,  646 
Cobb's  nasal,   330 
T)esault,  645  ^^ 

Dupuv's,  581 

for   C'olles'  fracture,  223,  265,  266. 
267 


Splints — ('ont'd. 

for    fractures    of    lingers,    :iir,),    3 10, 

31  1 
for    frai'turcs   of    furearm,   223 
lor    fractui'e   of    metacarpals,    304 
for   fracture  of   patella,  508,  500 
for    I'ott's    fracture,   668,   6(i0 
l)u])uytren'a,  668 
Stimson's,    660 
(ioldthwaite's,  311 
Ham,   500 

Hammond's   wire,   372 
lleatli's,  363 
llogden's,  582 
Kingslev's,  361 
Mata's', '  362 

Osgood-Penhallow's,    1 02 
plaster,    for    fractures    of    humerus, 
147 
for   fracture  of  leg,   648 
right-angle,    146 
Smith's,  646 
straight,    in    fracture    of   olecranon, 

101 
T-splint,   544 
Thomas'  hip,  540 
Walker's,  266 
Stereoscopic  X-ray  plates,  74,  751 
Sternum,   fracture  of,  453 
after-care,  458 
prognosis,  458 
surgical  anatomy,  453 
treatment,  456 

after-treatment,  458 
operative   treatment,    457 
Stimson's     dressing     for     dislocations 
of    outer    end    of    clavicle, 
35 
method  of  reducing  dislocations  of 

hip,  526 
method  of   reducing  dislocations  of 

shoulder,   60 
sjilints,  660 
Strapping,    of    chest,    for    fracture    of 
ribs,  463 
of  scapula,  402 
Stromeyer  cushion,   1 14 
Striicture  of,  clavicle,  12 
femur,  lower  end,  575 
shaft,  575 
upper   end,  531 
humerus,  upper  end,  83 
patella,  600 
St>loid  of  ulna,  fracture  of,  232 
vSubastragalar     joint,    dislocation     of, 
600 
after-care,  702 
diagnosis,   701 
prognosis,  702 
surgical  anatomy,  600 


810 


INDEX 


Sulnistragalar   joint,   dislinatioii   of — 
co»t'<l. 
symptoms,  7(10 
treatment.  701 

after-treatment.    7liii 
operative  treatment,  Tttl 
Subeorac'oid     dislocation     of     rla\  iclc, 
33 
of   shouhler,   iiO,   52 
Snltjilenoid     dislocation     of     siiouldcr. 

51,  58 
Snjierior  maxilla,  fracture  of.  3-13 
Surgical    anatomy    of.    dislocation    of. 
ankle,   (;S4 
astragalus.   ()!)'2 
calcaneum,  703 
carpo-metacarpal   joint.  'I'.H 
clavicle,   inner  end.  ."> 

(Hiter   einl.    30 
nilMiid.    71(1 
ell)o\v.    ]:^A 
fingers,   314 
hip,  515 
jaw,   370 
knee,  (513 
mandilile.    37(5 
maxilla.  370 
mediotarsal    joint,    701) 
OS  calcis,   703 
patella.  00!) 
pelvis,  402 
phalanges  of  foot,  720 

of  hand,  314 
radius,  head  of,   177 
scapula,  37 

semilunar  cartilages,   587 
shoulder,   44 
spine,   4G5 

subastragalar  joint,  OilO 
tarsometatarsal   jo'ut,    713 
ulna,   lower  end.   237 

upper  end.   175 
wrist,  277 
fracture  of,  astragalus.  002 
calcaneum.   70:5 
carpus,  277 
clavicle,    1 1 
cuboid,  710 
cuneiforms,   710 
femur,  lower  end,   574 
shaft,   558 
upper    end,    531 
fibula,  lower  end,  675 
shaft,  634 
upyjer  end,  620 
fingers.  307 
hip,  531 

humerus,  lower  end,   120 
shaft,    108 
upper  end,  82 


Surgical    anatomy    of,    fractvu'e    of — 
cont'd. 
inferior   maxilla,  348 
jaw,  lower,  348 

ui)per,  343 
malar.   334 
maxilla,    inferior,   348 

superior.  343 
metacarpals.   207 
metatai'sals,   714 
nasal  bones,  323 
olecranon,    185 
OS  calcis.  703 
l.atella.  504 
pelvis.  402 
phalanges   of    foot.    720 

of   iiand.  3(t7 
radial   and   uliuir   shafts.  204 
radius,  lower   end,  242 
shaft,  204 
U]>per  end,  107 
ribs,  450 
scaphoid,   710 
scapula,  37 

semilunar  cartilages,  587 
skull,  392 
spine,  465 
sternum,  453 
su])erior  maxilla,  343 
tibia  and   fibula,  lower  ends,  675 
shafts,  634 
upjier  ends,  620 
ulna,  lower  end,  232 
shaft,  204 
u])]ier  end,    185 
/.ygomatic  arch,  334 
of  Colles'  fracture,  242 
of  Pott's  fracture,  650 
of  seal])  wounds,  370 
Surgical    neck,    of    humerus,    fracture 
of,  87 
complicating'        dislocations        of 

slioulder,  72 
relations   of.   to   circumflex   nerve, 
105 
of  sca])ula,  fracture  of,  40 
Sutui-e  of  fragments    {see  Open  treat- 
ment of  fractures) 
Sutiuc     materials     in     treatment     of 

fractures,    768 
Suturing  of  fascia   in   fracture  of  ])a- 

tella,  602 
Swathe,   in    fracture  of,  huinerus,   101. 
104 
]i('l\'is.  507 
ribs,   404 
with    long   side   splint,    544 
Symptoms,  of  dislocations  of, 
ankle,  687 
astragalus,  694 


INDEX 


811 


Symptoms,  of  dislocations  of — cont'd. 
caleaiK'um,  705 
carpo-metacarpal  joint,   2!)5 
clavicle,  inner  end,   (i 

outer  end,  32 
elbow,  150 
lingers,  317 
hip,  520 
jaw,  377 
knee,  616 
mandible,  377 
maxilla,  377 
OS  calcis,  705 
patella,  610 
pelvis,  497 
phalanges  of  foot,  720 

of  hand,  317 
radius,  head  of,   178 
semilunar  cartilages,  588 
shoulder,  52 
spine,  473 

subastragalar  joint,  700 
tarso-metatarsal  joint,  713 
ulna,  lower  end,  238 

upper  end,  175 
fractures  of,  astragalus,  694 
calcaneum,  705 
carpus,  287 
clavicle,   15 
coccyx,  500 
femur,  lower  end,  578 

shaft,  561 

upper  end,  537 
fibula,  lower  end,  675 

shaft,  638 

upper  end,  625 
fingers,  308 
hip,  537 
humerus,  lower  end,  128 

shaft,  110 

upper  end,  89 
inferior  maxilla,  351 
jaw,  lower,  351 

upper,  344 
malar,  366 
maxilla,  inferior,  351 

superior,   344 
metacarpals,  299 
metatarsals,  716 
nasal  bones,  325 
olecranon,   188 
OS  calcis,  705 
patella,  595 
pelvis,  497 
phalanges   of   foot,   720 

of  hand,  308 
radial  and  ulnar  shafts,  206 
radius,  lower  end,  252 

shaft,  206 

upper  end,  199 


SyniptoniH,   frac'turcs  of — cont'd. 
ribs,  461 
scai)ula,  40 

semilunar  cartilages,  5HS 
skull,  411 
spine,  473 

su})erior  maxilla,  344 
tibia  and   filnila,   lower  ends,  075 
shafts,  63S 
upper  ends,  ()25 
ulna,  lower  end,  234 
shaft,  206 
upper  end,  188 
zygomatic  arch,  366 
of  Colles'  fracture,  252 
of  Pott's  fracture,  664 
of  scalp  wounds,  382 
Symphysis    pul)is,    separation    of,    502 
Syphilis  as  a  cause  of  fracture,  730 
Syphilitic    deformity    of    nasal    bones, 
327,  328 


T-splint,  544 

Tarso-metatarsal     joint,     dislocation 
of,  713 
diagnosis,  713 
surgical  anatomy,  713 
symptoms,  713 
treatment,  713 
Taylor  brace  for  fracture  of  clavicle, 

27 
Teeth,  loss  of  alignment  in, 

fracture    of    inferior    maxilla,    351- 

356 
fracture  of  superior  maxilla,  345 
Temperature,    in    fracture    of    skull, 
422 
in    various    forms    of    unconscious- 
ness, 429 
Terms,  725 

Thomas  hip  splint,  549 
Tibia  and  fibula,  fracture  of, 
lower  ends,  675 
after-care,  683 
diagnosis,   679 
prognosis,  683 
surgical  anatomy,  675 
symptoms,  675 
treatment,  681 

after-treatment,   683 
operative  treatment,  682 
shafts,  634 
after-care,  654 
diagnosis,  642 
etiology,  637 
prognosis.  657 
surgical  anatomy,  634 
symptoms,  638 


812 


INDEX 


Tiliiii   anil    lilmhi,   sliafts — iont'd. 
trcatimiit,  tl4-2 

aftt  r-trfutiiu'iit,  l>.")4 
iipt'iativc  trcatiiU'iit,  (ioO 
uppiT  ends,  (')20 
aftiT-iaic,  (ilJl 
(liajiiiosis,  t>27 
i'tiolo<;y.   t)24 

suijiiral  anatouiy.  (i'iO 
syniptonis.  (>2.> 
tn-atmcnt.  027 

aftfi-tn  atnu'iit.  ti:?l 
(•]ifrati\f  tnatnu-nt,  0"i!) 
'liliial     tiiluMilf,     aiHiinaltiiis     (issilua 
tii)ii   of.   (>-J-J 
iiijiiiy   to.  (•-- 
"lippinji"  of.  &1\ 
Toi-s,    fraftun-disliu-atioiis    of.    7"2(J 
prognosis.  721 
siirgifal  anatt)niy.   7'i(i 
synii)tonis.  720 
tifatniciit.  7"2n 
Transplantation  of  liont',  771 
I  raiiniatic  tlat-foot,  iil'-i,   7t)S 
'I  r(  atnicnt     of     compound     fraeturi,s 

and  luxations,  78!t 
I  ri'atnu'iit  of,  dislocation  of, 
ankle,  t)S<) 
astragalus,  G!)5 
caleancuni,  70t; 
cari)al  honi's.  2'.M 
carpo-nu'tacarpal  joint.   2iUJ 
clavicle,  inner  end,   7 

outer  end,  34 
elbow,   1()7 
lingers,  317 
hip,  524 

inferior  maxilla.  :!77 
knee,  (il7 

maxilla,  inferior,  377 
mediotarsal  joint,  70!) 
OS  calcis,  70(5 
patella,  611 
])elvis,  507 
])lialanges  of  foot,  720 

of  hand,  317 
semilunar  cartilages,  591 
shoukU'r,  00 
spine,   484 

subastragalar  joint.   7ol 
tarso-metatarsal  joint.  713 
thinuli,  317 
ulna,  lower  end,  230 

upper  end,   176 
wrist,  291 
fracture  of,  acetabulum,  507,  530 
acromion,  42 
astragalus,   0!t5 
bones  of  forearm,  shafts,  220 


Trcatnicnt    of,    fracture   of — vont'd. 
calcancum,   70(i 
I  arjial  bones.  2".i  1 
clavicle,   22 
iiilioid,    710 
cuneiforms,   710 
femur,  lower  end,  5S0 

shaft,   563 

upper  end,   542 
liliula,    lower    i-nd,    65.S,    tiSl,    68!t 

shaft.  642 

upper  end,  t)27 
lingers,    310 
Inniicrus.    lower   end.    143 

shaft,    113 

up|ier   end,  !t7 
malar,  330 
maxilla,   infi-rior,   357 

supciioi',  345 
metacarpal   l)ones,  301 
nu'tatarsal  bones,  718 
nasal  i)om's,  32!) 
olecranon,   l!tO 
OS  calcis,  7t)6 
patella,  598 
pelvis,   507 
phalanges  of  foot,  720 

of  hand,  310 
radial  and  ulnar  shafts,  220 
radius,    lower   end,   264 

shaft.  220 

ui>])er  end.  220 
ribs.  462 
scaphoid,  710 
scajiula,  42 

semilunar  cartilages,  5!)1 
skull,  444 
spine,  484 
sternum,  456 
til)ia   and   fibula,  lower   ends,  681 

shafts,  642 

ui)]ier  ends,  627 
ulna,  lower  end,  235 

shaft,   220 

u])per  end,   190 
zygomatic  arch,  339 
of  iJarton's  fracture,  269 
of  Bennett's  fracture,  305 
of  Colics"  fracture,  264 
of  Potfs  fracture,  iSiS^ 
of  scal|)  wounds,  385 
recuml)ent,  of  fracturi'd  clavicle,  25 
Ti-iangulare,  27!* 
Trigonvnn.  703 

Tuberosities  of  hunierus.  fracture  of, 85 
Turn  buckles,  Gerster's,  762 

U 
L  Ina,   dislocations   of    lower   end,   237 
after-care,  240 


INDEX 


813 


Ulna,     dislocations     of     lower     end — 
cont'd. 
diagnosis,  231) 
prognosis,  241 
surgical  anatomy,  237 
symptoms,  238 
treatment,  239 

after-treatment,  240 
operative  treatment,  240 
upper  end,  175 
after-care,  176 
prognosis,   176 
surgical  anatomy,   175 
■  symptoms,   175 
treatment,   176 

after-treatment,   176 
operative  treatment,  176 
fracture  of  lower  end,  232 
after-care,  235 
diagnosis,  234 
prognosis,  236 
surgical  anatomy,  232 
symptoms,  234 
treatment,  235 

after-treatment,  235 
operative  treatment,  235 
of  shaft,  204 
after-care,  228 
diagnosis,   219 
prognosis,  229 
surgical  anatomy,  204 
symptoms,  206 
treatment,  220 

after-treatment,  228 
operative  treatment,  225 
upper  end   (olecranon),   185 
after-care,   195 
diagnosis,  190 
prognosis,    196 
surgical  anatomy,   185 
symptoms,   188 
treatment,   190 

after-treatment,   195 
operative  treatment,  191 
Unciform    {see  Carpus) 
Unconsciousness     from     fracture     of 
skull,    differential    diagno- 
sis of,  429 
Union    of    fragments,    time    necessary 
{see   Prognosis   of   various 
chapters ) 


Uremic   coma,   436 

Tretlira,    injury    to,    and    rupture   of, 
in    fracture   of    pelvis,    509 
Use  of,   four-jjost  clamp,   763 

Lane  ])late,  76(5 

nails,  scr<'\vs  and   jjeg,  759 

wire,  758 

X-ray,  735 


Velpeau's  l)andage,  25 

in  dislocation  of  clavicle,  9 
Vertebrae,  fracture  of    {see  Spine) 
Vertical     suspension     in     fracture    of 

femur  in  cliildren,  565 
Vertigo  in  fracture  of  skull,  421 
Vessels,  meningeal,  396 
Visceral  lesions  in  fracture  of  pelvis, 

509 
Volkmann's  contracture,  231 
Vomiting  in  head  iniuries,  420 


W 


Walker's  splint  for  Colles',  226 
Whitman,    treatment    of    fracture    of 

femoral    neck    in    children, 

557 
Wire  nails,  754 
Wire,  use  of,  in  fractures,  758 
Wounds  of  compound  fractures,  789 
Woxmds  of  scalp,  379 
Wrist    {see  Carpus) 


X 


X-ray,  use  of,  735 


Y-ligament  of  Bigelow,  516 


Zygomatic     arch,     fracture     of,     334 
{see  Malar) 


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